Rolling Downhill

While I find the practice of Emergency Medicine periodically interesting and it has given me some wonderful opportunities in life, it’s not my ideal job. But since all the astronaut spots were taken, I’ve reconciled myself to my fate. However, one of the inevitable occurrences of doing a job you don’t love are those moments when you’re certain it’s the worst job in the world. I cognitively know that’s not true, so in a perverted version of Thomas Jefferson’s argument between his Head and his Heart l’m often host to an internal debate about what actually is the worst job in medicine. My Heart says it’s always me, especially on one of those days when nobody is really sick but everyone thinks they are, when all problems are chronic but demand immediate solutions, and when pain is ubiquitous but there’s never any good reason for it. But in the midst of my despair, it’s my Head to the rescue, reminding me that the worst job in medicine is…


The Hospitalist.

You probably don’t even know what a hospitalist is. Hospitalists are a relatively new innovation in medical care. A hospitalist is a physician (most often a specialist in internal medicine)who acts as the primary care physician for admitted patients. They do not work outside of the hospital in an office setting, and their efforts are limited to admitting and caring for the patients of private, office-based physicians throughout the community. What hospitalists really do, and their value to the health care system, depends on who you ask. If you’re inquiring of health care theorists, their familiarity with acute inpatient care makes them more likely to provide efficient, high-quality, low-cost care than physicians who only do hospital work part-time. If you ask the bean counters, hospitalists provide a service to the community physicians who will then drive their patients, and their revenue, to that hospital that provides that service and relieves them of after-hours duties. If you ask most physicians (off the record, of course), hospitalists exist so they don’t have to get up at night to see patients nor make hospital rounds during the day, taking time away from the more revenue-friendly outpatient practices and procedures. And if you ask an ER doc, the hospitalist is the one guy thankfully even lower than you on the food chain, the one for whom even your problems roll downhill.

To say that is not to disparage the hospitalists in any way. The vast majority of physicians I know who’ve chosen this kind of practice are good, smart, caring people, who provide excellent care in often the worst of cases and social settings. They accept anything and everything that needs admission. That includes critical patients with heart attacks and strokes, people on ventilators in respiratory failure, those with infections raging throughout their bodies, people needing emergency dialysis or cancer patients burning with fever. But it also means they admit anything we can’t get rid of, even if it doesn’t really need to stay. It’s not surprising to anyone in health care, but there are a lot of people who come to the ER and simply don’t want to go home no matter what. There are patients who are sent into the ER by their own doctor because that doctor doesn’t want to deal with them anymore, but you can’t abandon a patient without warning. So you send them to the ER and request that they be admitted so they become someone else’s burden while you prepare their 30 day notice, copy their records, and place them in a manila envelope by the receptionist desk. (For the record, when that happens and you meet the patient, you usually understand exactly why the doctor did it. ER Rule 84 J, Subparagraph 2: “If your say your doctor “fired” you, there’s usually a good reason for it. Subparagraph 3: “If you say you fired your doctor, see Subparagraph 2.) In both these, cases, the system as we know it doesn’t empower physicians to do what’s clinically right. It instead forces our hand towards doing what’s necessary to prevent complaints and lawsuits. Nobody gets cited for admitting someone who doesn’t need to be there, but paperwork flies when patient are tossed out no matter how valid the decision. One of the nicest things any colleague ever said of me is that I can talk patients out of staying and make them think it’s their idea. I’m kind of proud of that, just as I am for using phrases in the chart like, “tonight’s presentation has a distinct supratentorial component.” (That means crazy.)

So the hospitalist is the final link in the chain. When the patient genuinely needs to be admitted, or else just refuses to leave, they’re the ones who get the call. The great secret of the hopsitalist, however, is that their misery is transient. Usually the guy who admits you will be your inpatient doctor for one or two days, until their block of days on rotation is over and the you’re someone else’s problem…ummm…responsibility….wait…okay, I’ve got it now…and then someone else has the opportunity to help you continue to progress towards health.

Because they are always there for you, and are going to bail you out in the end with both that critical patient who needs hours of one-on-one care as well as that Marvin K Mooney who Won’t Go Now, you want to be their friend. Still, there are tricks. You figure out which ones want what tests done before taking an admission, so you speed up the process when you can. (In truth, most of the time an ER doc can tell you after the initial exam if someone needs admission or not. Most lab tests and x-rays are done for someone else.) Ones who are nicer to you get the nicer or more interesting patient when you have two to assign. If it’s fifteen minutes before the end of their shift, you stall just a bit and give the patient to the next one up. If you get along well with that doctor, maybe it’s twenty minutes. But no matter what, you always apologize profusely for any admission unless it’s so critical a case that you sound stupid in your haste to atone. And whenever possible, make sure to say that it wasn’t your idea to admit the patient, but that of the patient’s own physician and you’re just doing what he said.

Someone told me long ago that ER doctors will never have other physician friends, because when you call another doctor in the middle of the night it’s never to ask if they want a beer over breakfast. Yet hospitalists and ER docs tend to get along more than most. I won’t say we’re all best doctor friends, but if it’s lonely at the top it’s nice to be chummy at the bottom. More layers to dig out from the perpetual downhill flow. Hospitalists need us to skim off the top. We need them to rake out the bottom. And nobody else wants to get out of bed a moment too soon.