A Game of Inches

There are times I think it might have been interesting to have been born female.  And with the possible exception of recognizing that there were probably more opportunities out there for bright women than bright men in the early 1980s and 90s, most of it admittedly revolves around sex.  It might have been nice to be in control rather than the begging.  I like breasts, and it might have been fun to have my own.  It might have been nice to be able to have multiple orgasms, and not leave a mess or develop wrist sprain from holding a magazine when doing it by yourself.  (So I’ve heard). But then I think of periods, and childbirth, and makeup/clothes/shoes, and the fact that the guys you want to have sex with may not be the guys who want to have sex with you, I’m okay with the way I was born…quite happy with it, in fact, thank you very much.  (That being said, through life in the ER I’ve come to recognize that given the right circumstances…often meaning cigarettes, beer and methamphetamines…just about anyone will have sex with anyone else in a burst of Darwinian frenzy.)

I was reminded of another difference the other day when a self-described adult entertainer came in late one night complaining of a lost object.  I should specify that the term “adult entertainer” is used rather loosely in our neck of the woods.  I mentioned in a blog post some time ago that I believe advancement in the Erotic Dancing Guild of America works on a farm system.  If New York, LA And Las Vegas are the majors, then dancing around here is…well, rookie league short season at best.  To be blunt, she wasn’t the kind of hottie for which your hard-earned twenties longed for her g-string.  Instead, you might take some nickels and throw then in the other direction, hoping she’d follow.  (I should note at this point that there are two Guild establishments of note in Our Fair City.  One is called Sasnak, which is Kansas spelled backwards.  It’s known for having a bin of free hot dogs in boiling water available day and night.  The other is Club Orleans, a place out by the interstate that seems to me to be pretty dark during most of the year, but lights up on weekday nights during the four months of the legislative session.  The Universities have to get their funding somehow.)

This particular Pole Professional had lost an absorbent monthly hygiene product.  It had bee appropriately placed for a very sensible reason…if I might quote, “You can’t drip and dance.”  But the string had unfortunately been lost , and she couldn’t pull it out.  It happens.  Fair enough.

(Which reminds me of the time a surgical intern at the University of Florida…who is probably now some Chief of Cutting Brains at Harvard, for all I know…came running out of an exam room to tell me there was a harry mass within a young woman’s nether regions.  One of the finest moments of my teaching career came in pulling the mass out with a pair of forceps while the intern winced, explaining the difference between a hairy mass and a ball of cotton fibers, and directing him to purchase a “little something” for his girlfriend as research.)

Enter the boyfriend, a hulking specimen of Homo Ergaster (and I say that knowing it’s not, as Groucho might say, fair to the other Ergasters) sitting in the chair in the corner of the room, with the aroma of self-assurance that comes with an adverse disposition to authority.  “She says it’s there, but we had sex and I didn’t feel it so she’s wrong.”

An interesting difference of opinion, to be sure.  The clinical issue was simple.  Do an exam, remove the object, atomize the room with the toilet water of reassurance, go in peace, peace be with you, and also with you, and have a nice day.  Which we did.  But the whole scenario begs two questions:

1.  How many women do you need to have sex with to be able to tell the difference between interacting with female soft tissues or a tampon?
2. If the length of the average vagina is 3-4 inches before arousal, and if the tampon takes up two to there inches of that, exactly how small do you have to be to not notice the tampon is in there?

Neither of which I chose to ask, thinking my life was more valuable (at least to my creditors) that the information I might receive.  But I suppose it doesn’t really matter.  As long as I can still feel the pericardium in those more intimate times, it’s all good.

Popes and Governors

When I heard about the “Come to Jesus” talk given by Pope Francis to the Vatican Curia last month, it made me think about our own local politics here in Flyover Country.  In recent months there’s a lot being made of notes scribbled down by Kansas Governor Sam Brownback regarding an anti-abortion bill he was about to sign.  The Governor is a strong Catholic, and apparently he wrote the words “Jesus + Mary” in the margin of a statement he was about to make before signing the bill.  Personally, I don’t have a big problem with that.  When I was in public life, I made marginal notes to my presentations all the time.  And I don’t have a problem with your spiritual views informing your political stands, as long as legislating your beliefs do not impose upon mine.  (I’m not a theologian by any means, but I would argue that the heart of any religion is the acceptance of a particular interpretation of history, while the heart of belief is a personal spiritual experience.  They key word is here is acceptance, not compulsion.)  

So I’m okay if you want your religious beliefs to influence public policy.  But what I would I ask you to do is to be consistent.  And this is where Governor Brownback…and in fact most of our legislators, both in this state and nationwide…fail.

While I may not agree with the doctrine of the Catholic Church, I admire that it is always consistent in its beliefs.  Take the Church’s emphasis on the culture of life.  That leads to a strong stance against abortion, assisted suicide, euthanasia, and the death penalty, and a rigid belief in the sacrament of marriage.  But it’s hard to believe that a Governor who clings to the “culture of life” also believes that the lives of Kansans will be bettered by withholding Medicaid coverage from them, and by farming out management of the meager programs that exist from low-overhead, high-service government agencies to high-overhead, for-profit entities whose best interests are served in minimizing expenditures and denying care.  A culture of life would include common-sense measures such as background checks for all gun owners and the abolition of high-capacity magazines and automatic weapons.  It would understand that when more citizens carry concealed weapons, a heavily armed society always walks on edge, and life becomes so devalued that everyone is given the opportunity to kill for the barest of reasons and be vindicated for doing so.

Pope Francis has made clear the Church’s longstanding interest in social justice.  And this makes one wonder why a Governor who proudly proclaims his stance with the Church thinks the world is really better off with funding cuts to education, the one ladder the poor have to climb the ladder of success.  How do regressive income tax cuts, which impact the poor more than the rich, and proposals to take away tax deductions for home mortgages and create a whole new class of permanent renters, help people contribute to the economy and support their families and themselves?  How can proposals (wisely defeated by legislators) to defund the Kansas Neurologic Institute, the last refuge for those who are so mentally handicapped or physically impaired that they require the most intense and compassionate care, be considered anything but an attempt to cast the most defenseless among us to the street?  How can one reconcile the ideals of a true democracy…the empowerment of the government by an empowered and informed people, the ultimate expression of social justice…with plans to disenfranchise voters and to permit politics to be run by money and not ideas?

The Church has emphasized the need to be better stewards of God’s marvelous handiwork that we call the earth, and supports the use of science to better understand the miracles of the universe.  It would follow that we should use science to enhance our stewardship and preserve that which God has given us.  It cannot square with recent movements in Kansas, unrepudiated by the Governor, to outlaw local governments in pursuing sustainable growth and development policies, to discourage regulation of polluting industries, and to force reliance on non-renewable resources.  (As best I can tell, this movement is simply a result of the fact that the United Nations supports sustainable growth.  And other evil things, like peace.)  And how can bills requiring physicians to give patients false information about abortions, or proposals to provide physicians immunity if they choose to withhold information from patients simply to achieve a political aim, be true to the Church’s support of scientific integrity, let alone the inherent dignity of each person created in the image of God?  And if the Church has always supported the arts as a way to call more attention to the majesty of God and his creation, what makes it right to defund public arts programs?

Of course, it’s easy to be contradictory like this when your goal isn’t spiritual.  Whether or not you agree with their teachings, our most recent Popes have been all about service.  Governor Brownback, and the majority of our policymakers, are all about ambition.  In the case of the Governor, there is no question that he sees his future outside of Kansas, as a leading voice in the conservative movement.  There are some that think he will run for President in 2016 (apparently forgetting his eminently forgettable 2008 run), and is using Kansas as a springboard, enacting policies with an eye towards how it will impact his standing within the far right wing of the Republican party rather than how they affect the very people he was elected to serve.  I have to confess I sympathize with this point of view, and some days I have trouble believing he gives damn about Kansas, and is doing anything but simply building his Tea Party credentials.  By the time the effects of his policies come crashing down upon the state, he’ll be long gone and unaccountable to the voters, leaving someone else to face their wrath and clean up the mess.

I’ve never met him personally, but I’ve been told that Governor Brownback is basically a good man with deeply held spiritual beliefs.  That may well be true, but if so it’s time to show them.  If he doesn’t, or can’t, you’re left with only two choices.  One is that he simply lacks the brainpower to figure it out.  The other is that he’s nothing more than a self-promoting ideologue who can’t see the forest for the trees.  You know, trees…like the ones used to make the cross of Jesus.

Bells and Lullabys

A number of hospitals that I’ve worked at have ways of letting the whole place know when someone has had a baby.  The child pops out, someone somewhere pushes a button, and over the loudspeaker little bells ring and lullaby music penetrates to every corner of the building.  I understand why they do it.  The birth of a child is a joyous event for a family and for the community as a while.  That being said, I’m not so sure that’s true for the baby itself.  If you think about it, the kid had it pretty good.  Warm, snug, and well fed.  Not a care in the world and nothing to do but take naps and lie there, coiled up, looking at one’s own endlessly fascinating genitalia.  Perhaps this is why it’s said that men spend the first nine months of their life trying to get out of the womb and then the next 70 years trying to get back in.  It’s really a helluva deal.

Of course, being ER folks we have our own twisted perspective on these announcements.  We know from statistics that that over 40% of births in this country are covered by Medicaid, and that Medicaid patients go to the ER at double the rate of those with private insurance.  We know that most private pediatrics offices solve the problems of after hours care by referral to the ER.  We know from experience that as a society our families are failing, and that many have become dependent upon institutions to care for their children rather that doing that work themselves.   So when we hear the music, all we hear is more work for us.  Job security, I suppose.  But on the whole, we’d rather not know.

The Critical Frog and Me

Rumor has it that I am the parent of a frog.  Not any frog, mind you, but specifically a critical one.  I know this because he blogs under the name of The Critical Frog at thecriticalfrog.blogspot.com.  And because he has a coffee cup from Senor Frog's in Cancun.  Also there's a plastic model of The Visibile Frog complete with little molded organs sitting upon his dresser, which is creepy, especially if you think about waking up in the middle of the night and there's a set of painted frog organs looking back at you in the moonlight streaming through the blinds.

I bring this up not only because The Frog is my own declared progeny, nor because I think he's an insightful writer with a creative use of language and narrative.  I do so because in his latest piece, ("Night at the Museum 3:  Secret of the Tomb," at thecriticalfrog.blogspot.com), he's noted that we agreed to jointly review the aforementioned film because we disagree about the ending.  This was actually his idea, and I think it's kind of cool.  Plus if this works, I can have at least a minimal claim to bask in his aura and hopefully his checkbook) when he's the next Ben Mankiewicz.  

The movie was a project for last Monday afternoon.  The hospital where i work had decided to reward my sleepless nights and lost clothing due to various expectorations with a pair of free movie passes (INVALID FOR 3D OR SPECIAL PRSENTATIONS) for the holidays.  So it was off the the theater we went that afternoon, with plans to follow the film with a trip to Red Robin for burgers and bottomless fries to follow.

(For the record, I've never understood the whole bottomless concept, at least as it pertains to food. If you have bottomless fries, does that mean someone bites them in half to remove the bottom before you get to them? And which side of the fry is the bottom, anyway?  A bottomless cup of coffee would spill out the base of the cup and scald your most tender rwegons.  I do understand the concept of bottomless in terms of liquor licenses and zoning regulations, but that's an entirely different conversation. And yes, I'm a regular Edwin Newman when to comes to language.  This morning I was doing a computer training that said after you interacted with a receptionist, you were "recepted" instead of "received." Drives me crazy.  Also, please use your Oxford commas.)

I don't review movies.  That's clearly The Frog's forte.  So I will try to summarize the plot and our points of contention,  and if my description doesn't make sense please see his take on it because then it most assuredly will.

Night at the Museum 3 is the latest installment of a family-friendly franchise starring Ben Stiller and Robin Williams.  In the first picture, Larry the Security Guy (Stiller) finds that there's a magic Egyptian amulet at the American Museum of Natural History (AMNH).  The magic brings the exhibits to life at night, most notably a paraffin Theodore Roosevelt (Williams).  There are laughs and a minor conflict, but all resolves well and everyone dances through the credits. ("Now is the time on Sprockets when we dance!")  NATM 2 takes the same premise to the Smithsonian.  The New York gang goes to DC, a few more things come to life, another minor problem is happily resolved with pleasant laughs, and the party goes on as the credits roll.  Both are perfectly serviceable family moves that I enjoyed, and would be happy to watch again while sitting on the couch with a cup of hot chocolate in my and and a dog somewhere near my feet while the winter wind howls outdoors..

NATM 3 has a slight twist on the theme, in that the magic amulet is running out of power, and the only person who knows how to fix it it the father of the mummy who owns the amulet in New York.  The mummy's father...who is also a mummy...and his Mommy, or mummy, or Mommy mummy...are lying at the British Museum.  So Larry and his reanimated crew take the tablet to London, a few more things wake up, things wake up, they save the amulet, and there are good-natured laughs.  There are some brilliant subtle lines as well, including a discussion regarding the exodus of the Jews from Egypt; as  Larry says to the Pharoah, as memory serves:  "It's a long story.  You wouldn't like it. We get together and talk about it ever year."  (Kind of like the line in the Book of Mormon that "I beleive...that the Garden of Eden is in Jackson County, Missouri, which only makes sense if you're from Kansas City, because they DO.)  There is also Robin Williams' last ad-lib on film; speaking of his love for a model of Sacajawea that shares the night time magic, he notes, "I'm wax, she's polyurethane, but it works."

As a family film, NATM 3 is full of predictable messages about family and friendship, the occasional monkey excretory visual (to make sure we appeal to preteen boys...well, all boys), and a goodly amount of light chuckles to keep the story fun.  It's totally pleasant, reliable entertainment, and a nice way to kill a few hours on a cold winter's afternoon.  I left the theater pleased that I saw it.  Probably not going to invest in the video, but didn't walk out dazed after I did with Avatar,  wondering how I was ever going to get those eighteen hours of my life back.  (What do you mean Avatar ran only three hours?  Are you sure?)

The Frog and I both enjoyed the movie. Where we disagree is in the ending, and here is AN OFFICIAL SPOILER ALERT.  Towards the end of the movie, the magic amulet is now back with its owner in London.  And the mummy that was in NYC is now reunited with his family in London.  So the exhibits from NYC who have come to London to help Larry in his quest decide they will leave the amulet in London, giving up their nocturnal existence in order to keep the Pharoah's family together, explaining that they still have value as exhibits helping others to learn.  It's a gentle way to communicate a powerful message about self-sacrifice and the legacy that lives on after us when we leave this word.  And this s where The Frog says the movie should end.

And this is where I disagree, for a few minutes later (three years in movie time), you see where the AMNH is now featuring an exhibit called Treasures of The British Museum.  And...who knew...the magic tablet is back, and not only have our old friends come back to life but they are now joined by those we've come to know from England.  There's a party, and music, and dancing.  Roll credits.

The Frog contends that the movie should have stopped before the last coda.  I think the latter was actually the better ending, simply because the movie was not made for the sake of character or plot, but for us.  NATM 3 is not an art film, nor a tribute to Method Acting.  It's not a novel by Jose Luis Borges or James Joyce.  It's a mass market flick, a paperback to read on the beach.  You've come to like these characters.  You want it to end pleasantly.  You want to think they aren't forever stilled.  And we can still invoke the messages of self-sacrifice, but this time with the promise of a reward at the end. Which is pretty much what most of our world spiritual traditions do.

(I do understand his viewpoint, however.  Some movies...even very good ones...go on too long.  Michael Keaton was remarkable in Birdman, but it ended a minute and a half too late.  I won't disclose the whole story, but once having broken new theatrical ground, there was no reason to open the window and jump. Or fly.  Whichever.)

As I try to break it down, where The Frog and I disagree is not about the ending, but who the ending of a movie is for.  He thinks it's for the characters; I think it's for us.  We have different needs in our real world then they do in theirs, and there's more of us then them. And, as we've learned, the needs of the many outweigh the needs of the few.  Or the one. Even if he's My Very Own Teenage Amphibian.

Merrily We Troll Along

Chronic readers of this blog (whom I trust are taking some kind of medication to control this) know that I have an affinity for coming up with new and different ways to objectively triage our patient populations.  I would be remiss if I gave the impression that I was the only one involved in this critical work.  One of my colleagues who has a special interest in the recidivist nature of some of our clients has been expending considerable effort in developing what she calls the Troll Score.  She has graciously invited my participation in the effort and, as I am always willing to advance medical science as long as it doesn’t involve me being instrumented in any way, I have most modestly agreed to help. 

Trolls are those patients who feel at home in the ER.  We want to ER to be a comfortable place, somewhere that people with illness or injury can come without fear.  However, we don’t want it to be too comfortable, as we have no desire to adversely impact the booming homeless industry.  The ER is like a highway overpass, a safe place to pull your car off the road during a downpour, but not someplace you should like so much that you set up camp and stay.  Trolls live under the bridges all the time, every now and then surfacing just long enough to snatch a tender young goat from the road above and drag it down to it’s doom. 

We all have our favorite trolls, those whose lives revolve around each ER visit and who, when discharged, simply can’t wait to get back.  Sometimes a troll returns not by choice, but because he has too.  If you ask most of our intoxicated citizens, they really would be perfectly happy sleeping it off wherever they fell.  Because most of them fall in the street, however, the police feel compelled in the interests of road safety to bring them in.  But many trolls also seek opportunities to come to the ER.

I’ve got two favorite trolls, one in each category.  In the first group is a one-legged man named Gene.  Gene gets drunk outside a specific convenience store (“You know, the one where all the Indians hang out.  The feather Indians, not the dot head ones”) and lies down.  When the police wake him up, he gets mad and fights, usually by taking off his artificial leg and swinging it about.  The way you deal with him, of course, is to put his leg in the corner out of reach and put him in three point restraints (because there’s no fourth point) and let him flail his stump like a grounded seal.  Four hours later he wakes up, is as pleasant as he can be, declines your offer of an admission for detox (“I’d like to tell you I'm interested, but I got be honest and tell ya it’s just not so”), puts his leg back on, and goes out to face a bright tomorrow.

Barbara is in the other category.  Barbara comes to the ER once a twice or week complaining of shortness of breath.  She has emphysema, so she's always short of breath, never any better, but never any worse.  But she likes Denzel Washington, and out hospital has a version of Movies On Demand for patient rooms.  So she calls the ambulance which brings her to the ER, it takes us about an hour and a half to prove that she is not having a medical emergency, which is just enough time for her to have a sandwich, a Sprite, and watch “Remember the Titans,”  When the movie's over we tell her to leave, and she says she can't go back to the death trap that is her home, and I point out that she's still alive so it can’t really be a deathtrap after all or she'd be dead.  She scowls and calls a taxi.  I was a little worried because we didn’t see her for about three months, and was afraid maybe, at long last, she was right.  Not to fear.  She’s back.

Drug seekers are a special kind of troll.  You can find something quirky or amusing about most true trolls.  Drug-seeking pseudo-trolls have no redeeming features at all, and the race is to see how fast you can get them out.  Preferred techniques are to tell them how many times they’ve been in the ER and ask if that number is excessive or to point out that other doctors have expressed concern about their use of narcotics, and you’re going to honor that concern no matter how many times they say their cousin stole their prescriptions.  Phrases like these are objective and factual, but clearly send the message that there’ no Lortab for you.  A true ER doctor feels a certain measure of success when a drug seeker comes to the ER and leaves as soon as they find out who will be their doctor, because it means that they are less likely to come back.  In a job where everything is transient, you can finally have a long-term impact.   

(The “cousin” line is actually pretty amateurish.  There are a lot of better ones.  It’s always fun when the patient blames us for cutting his pants off in the ER that had the prescription in his pocket, or that the police took his bottle of pain pills from him in jail and simply will not give it back.  But one of my all-time favorites was the guy who said he had loaned his car to a friend to drive to Mexico, only to find that he had locked his narcotic pain medications in the glove box where he kept them for safekeeping.  “He’ll be back next month, but in the meantime I’ve got this pain…”)

But back to the Trolls.  The Troll Score is used as a triage measure of the chances that you will actually be able to affect any change in the patient’s condition during the ER stay.  The value of such a score is immediately apparent.  In these days where rapid patient turnover is prized by hospital administrators and decreased costs are dear to health care policymakers, being able to know from the first moment you step into the room if your care will make any difference at all to overall outcomes allows to minimize your time with the patient and pare the costs of care to a minimum.  After much reflection…well, some at least…here’s what I’ve developed.

Troll Score:

Suspected alcohol level > 300, yet patient is fully awake and alert     (5 points)

Number of stool softeners     (Multiply x 2, 1 point apiece)

Number of ER visits within a twelve month period     (1 point each. Immediately double if any visits to two or more other ER’s within sixty miles)

CT scans of any type over last two years (1 point each.  Add 20 points if patient glows)

Statement that patient has “fired the doctor”     (10 points per physician)

Statement that “the other hospital treated me badly”     (10 points per hospital)

Any use of the word “disability” (10 points per qualifying condition)

Normal vital signs despite complaints of severe pain, trouble breathing, vomiting, fever, or parasitic alien infestation     (20 points)

Any mention of fibromyalgia.     (20 points.  Add 10 more each for associated irritable bowel syndrome, chronic fatigue, or a prescription for gabapentin.)

Any behaviors that imply a working knowledge of "The Great Big Purple Book of Crazy," otherwise known as the DSM-V (20 points)

If I’ve done this right, we should end up with a scale that plots out like a logarithmic curve, with higher scores representing those patients with a lower chance of finding anything actually wrong and therefore the least chance of making an impact on their disease and final outcomes.  Once validated, the physician could look at the score and say to the patient that the evidence (because we’re all about evidence-based care, right?) suggests there’s nothing we can do for you and would you please go home.  Turnover time minimal, negligible costs.  And maybe actually communicating to patients an educational message about their use of the ER.  Perfect.  But let’s not have anyone go away mad.  How about a turkey sandwich and a Sprite on your way out the door?

Hauntings

The first sign of trouble is when the nurse says she needs you in the room NOW.  The second was when I came bedside and saw a scared middle-aged man.  There’s different kinds of scared.  There’s anxious scared.  There’s uncomfortable scared.  There’s “what are you going to do to me?” scared.  And then there’s the “I’m going to die right now and there’s not a damn thing you can do about it” scared.  That was him.

One of the problems about medical writing in the era of patient privacy is that if I tell you too much about the case, someone can figure out who it was.  But here’s what I think I can tell you.  He had overcome significant medical issues to live a happy and productive life, graduating from college, spending time with family, working until his condition no longer allowed him to do so.  And I can tell you he was scared, and he was dying, and he knew it.  So did I, and everyone else in that room.  You don’t come in the slightly off-white color of grade school paste and leave standing.

Over the course of an hour, we tried to figure out why.  Infection?  Nothing obvious at first glance.  Internal bleeding?  Nope.  He kept going downhill, his breathing more labored and his blood pressure falling, until I said, “I think we need to put you to sleep and put in a tube into your throat to make sure you get enough oxygen.  Is that okay with you?”

He nodded.  Scared.  Me too.  I told him we do this a lot, that we’d keep him asleep to make sure he didn’t have any pain, and we’d get him over this.  He nodded.  Scared.  Me too.

I put him to sleep and the procedure went fine.  He started to move after the initial medications wore off, clearly in pain, and for a brief few moments he looked at me, around the room, back to me.  Then, mercifully, the meds kicked back in again, and he was responsive no more.  Or ever again.

Eventually, we found out why he died.  And there was nothing that anyone could have done to stop it.  A long valiant fight had been lost in the same way we’ll all eventually lose.  I sometimes make myself feel better by thinking that in our business, if you even save 1 out of 10, you’re still batting .100 against God, the greatest pitcher there ever was.  Not a bad average in the long run.

Do you want to know what haunts a seen-everything, done-it-all, been-doing-this-far-to-long ER doc? It’s lying to a patient who’s scared to die, and that the last thing they saw before they went to  their forever sleep was your face, and the last thing they heard were your words.  Lying.  And they knew it.

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.