American College of Physicians: Internal Medicine — Doctors for Adults ®

Friday, September 5, 2014

Dr. Nobody

Today I had a very special experience, one which many of my patients have faced: I was treated like a nobody while at the hospital. Yay me.

I went to visit a patient who was admitted over the weekend to see what was going on. She was a bit upset about the confusion of the hospitalist service and how orders apparently didn’t get written for her care by the admitting physician. That’s been resolved, but there are still many questions about what is going on with her and I thought that maybe I could help.

I was actually hired by this hospital when I first came to Augusta 20 years ago. They paid for my first 2 year’s salary and got my practice up and running. After concluding we could run our practice better than the hospital, we left their employment to run our own business.

I continued seeing inpatients in that hospital over the years, although I did give up the practice of admitting my own adult patients, opting to use the “hospitalist” service, something that was still fairly new when we went over to it. We felt that the negative of the loss of contact with our hospitalized patients would be greatly outweighed by the improved care we could give to the vast majority of patients who were not in the hospital.

This is a deal with the devil that many docs have made over the past few years, as the overwhelming burden of paperwork, codes, and insurance nonsense made us look for ways to simplify. It’s a deal with the devil, though, because we lose contact with patients when they need us most. This is made worse by the #1 rule most hospitalists seem to have: Never communicate with the primary care physician. I’m not sure why they have that rule, but it has been consistent through my years of practice. We primary care physicians are either evil, stupid, or very dull conversationalists. Hospitalists hate us.

Still, I am well-known to most of the other physicians in that hospital. It carries a lot of memories and good feelings. I was actually a bit excited to go there and perhaps bump elbows with the doctors and nurses who still know who I am. But from the start, the experience was less than positive. Since I am now a “nobody,” I no longer have access to the doctor’s parking lot and had to park with the “common folk.” This is fine, but the patient lot bakes in the hot Georgia sun and was packed, resulting in a long, hot walk to the building.

The hospital has changed a lot since I was seeing patients there. With all of the economic pressures they face, I find it curious how many multi-million dollar “improvements” get done on a regular basis. Walking in, it looked totally different and I knew nobody. The elevator was dressed nicely in real wood paneling and multiple advertisements for their “Da Vinci” robotic surgery. They spent a lot of money on those robots, and need to get some of it back (despite a lack of evidence robotic surgery is better).

My patient’s ward was the usual mix of patient moans, nurse call chimes, IV alarms, and distracted nurses. I found the room and went in, greeted with a big smile from my patient and her husband. They told me the tale of woe, recounting the sickness itself, the ER experience, the orders neglected, the doctors not answering their pagers, and finally the nice hospitalist they finally saw. They couldn’t answer many of my questions, as they hadn’t really talked to many people despite 2 days passed.

I went out to get a pen so I could give my cell number to the hospitalist (hoping he doesn’t remember rule #1), plus I wanted to see if I could check the chart and get some answers for my patient. After being ignored by the nurses for a minute or so, I cleared my throat, winning an icy greeting from one of the nurses. I explained that I am a primary care provider and needed a pen, also expressing my hope that I could see the chart. ”No,” she said simply. ”You can’t look in the chart unless you have privileges and have been consulted.” She wordlessly added through her facial expression: “and stop wasting my time, you useless pile of crap.”

So now I wait, hope against hope that the hospitalist will break the hospitalist code and actually call me. Today’s experience made me once again see how badly our system treats people. I was Dr. Nobody while I was there. Each patient in that hospital seems like a nobody attached to a set of problem codes and procedure codes (which may, by the way, be fixable using “Da Vinci” robotic surgery!). The nurses are overwhelmed and the doctors are hard to reach. They don’t know my patient, and will soon forget about her when she leaves. This is not health care, it’s a chaotic money-devouring machine.

I left there ever more committed to keeping my patients away from that mess. My patients are not nobodies; they are people I’ve taken the time to get to know. To them I am not Dr. Nobody; I am their doctor.

Take that, hospital.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.

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Anonymous J Pollock MD said...

I am sorry to hear about your experience. As someone who until recently consulted a 7 different hospitals, I have frequently had the experience of going up to the nursing station and finding no one available to discuss by patients. The nurses are frequently short staffed and sometimes on edge.
I would think if you had courtesy priveleges you should be able to look at the chart. Also, it may be a good idea because almost every hospital I have gone to is now based on an EHR- there is simply no paper chart anywhere. You would need a log-in just to get into the computer based medical record. But the advantage is that you can most likely view the chart remotely in your office or home, and you can review the hospital course independently when the patient comes to you for follow up after hospitalization.
Lastly, page the hospitalist. They need to know that they can't take the lazy way out. Once they are on notice that you want a report at discharge, they will start to do it. But if you don't give them that expectation, they will just continue to send your patient's out with instructions to follow up with the PCP in 1 week. If you find this is a consistent problem, then I would call the head of the hospitalist service and remind them that there are other health care systems for which you may refer your patients.

September 6, 2014 at 8:29 AM  

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

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Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

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Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

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Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

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PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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