Unlike ER doctors, who handle urgent crises hour-by-hour, hospitalists manage the day-to-day care of patients with serious but not immediately life-threatening conditions.
At any given time, a hospitalist typically manages 8-10 patients, most of whom are new to him. Their job is to quickly gather information from medical records, patient interactions, and test results to diagnose and ultimately discharge patients.
Hospital physicians act as medical coordinators. They are trained in high-level diagnosis, but they refer immediately to specialists for specific interventions. In many ways, they act like PMS Hospital: Aligning stakeholders, tracking progress, and ensuring patients are on the right track. They may order tests such as MRI but generally leave interpretation and detailed recommendations to specialists (such as surgery).
The following is a selected assortment of my travel notes:
- Everyone jokes about death.
Everyone, including doctors, nurses and support staff, jokes about death in a way that is unsettling to an outsider. This is best understood as emotional splitting as a survival mechanism, not insensitivity. This makes sense, as it enables them to create a barrier between themselves and death. I imagine this is one of the most effective ways to create a positive work environment, as well as enable everyone to do their best work without being depressed all day looking at people dying.
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Verbal communication is key to transferring updated knowledge, while written notes are often an afterthought.
When I first got there, four surgeons were having a stand-up meeting at a nearby table. Throughout the night the surgeon explained the details of the surgery he had just performed, while others tried to listen and take a cursory look at the patient’s chart at the same time. She had to repeat herself several times because they asked questions she had already answered.
when doing morning roundsThe hospitalist never took notes during the meeting. Both the medical students were roaming around taking notes in their notebooks. After meeting the patient in the hallway, the doctor and medical student will discuss the diagnosis and recommendations for next steps. There was little disagreement as the next steps were generally clear. In one example, the medical student reminded the hospitalist of one of the symptoms that the hospitalist had forgotten about during a 15-minute conversation. The hospitalist usually remembers everything but sometimes writes a quick note of 1-5 words on his phone for future charting.
In the afternoon, medical students wrote detailed reports on the patients they saw, joking with the doctors that this was not the best use of their time. Hospitalists reviewed these articles as part of the students’ end-of-rotation evaluation.
I asked if he ever revisited old cases to track a patient’s progress. Both shook their heads: “No, it’s not part of the curriculum – and we’re too busy.”
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Information asymmetry among employees due to the predominantly verbal communication culture leads to repeated clarifications and lost context.
Because documentation is written retrospectively (usually at the end of the day or the next day), the most recent information is obtained by asking around. This allows search operations to be carried out, individuals around the building are monitored to obtain specific information that can be easily recorded.
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everybody Hates epic,
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The quality of your medical care can be determined by the reception of the carrier when a specialist is having lunch.
The hospital I visited is part of the HMO system. This means that hospitals and specialists are employed by the same organisation, allowing more regular communication and shared referrals.
There were several instances where the hospitalist called in a specialist for a second opinion to read the chart or consider a recommendation. Often, we were in a wing of a building where cell reception was very poor, likely due to machinery and other cell signal limiting infrastructure. All calls were routed through standard cell carriers, not through Wi-Fi (even though Wi-Fi was consistently good at all points in the building). There were several instances of difficulty interpreting segments of the call due to poor call quality.
On call, a specialist will recommend a specific medicine and the hospitalist will type it into Epic and populate 8 medicines in the search query. The hospital man followed and asked which one it was. It turned out to be the fourth option, hidden behind sandwiches, chips and the noise of a relatively thick accent.
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Hospitalists are well-organized extrapolation machines.
The job of a hospitalist is to make an accurate diagnosis based on all the available information. The information is either test results or discussions with the patients themselves.
The test results give you lots of clues and are usually accurate. However, doctors are trained to treat patients, not test results.
Patients often lie, and the best doctors treat it as part of the conversation, and provide the best care within existing constraints (available testing, insurance, etc.). Patients often lie to doctors and tell half-truths. Years of training allow them to make quick decisions based on both conscious and subconscious cues.
In many ways, they are part negotiator and part matching engine.
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Doctor qualifications are highly variable, as there are little incentives for improvement.
The hospitalist I was shadowing had one of the lowest average hospital stay days for patients, which is a testament to his ability to efficiently diagnose and get patients out of the hospital. All else equal, this is a good thing because being in the hospital is bad for your health because you are sedentary and stressed.
Subjectively, he was one of the better hospitalists present that day (I also shadowed two others throughout the day during slow periods). The other two hospital workers acted with much less promptness and promptness.
For a patient in his mid-60s, the specialist at the high-agency hospital I was in contact with ordered a specific test, given the symptoms, which came back positive for cancer. This probably resulted in the cancer being detected at least 3-4 months earlier than it otherwise would have been.
But all hospitalists are paid under the same schedule (based on years of experience), meaning that higher-agency hospitalists are being paid the same as their counterparts. Greater intrinsic motivation and ability are not explicitly rewarded.
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Doctors know who is good, they just won’t tell you.
An orthopedic surgeon in the organization is 60 years old and has performed many knee surgeries. One of the most common procedures for a torn meniscus. This surgeon was trained to remove only the entire meniscus, a practice no longer recommended because it can lead to arthritis. This surgeon does not repair the meniscus, which has been the preferred method for the last 10-20 years.
Hospital doctors and other doctors are aware of these differences. They generally recommend alternative surgeons trained in meniscus repair, while referring older patients—who are likely to require complete meniscus removal anyway—to a removal surgeon.
Hospitalists will always say simple things like “X is a highly competent surgeon”, even if he is not at the top of their list.
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Doctors are mostly encouraged to be highly agreeable and take less risk.
Being contradictory and correct is unrewarding and increases the workload on your teammates. Common diagnoses are safe and will not void your malpractice insurance.
Everyone gets a chance to go home early to their kids.
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The social divide between doctors and nurses is clear.
While HMO hospitals create a flat structure among all hospital staff, there is still obvious tension between doctors, nurses, and support staff. During break periods around their desks, nurses often sit around each other in a relaxed state, chatting and updating each other about their lives.
When a doctor tried to join the conversation, the situation changed, and it never felt the same. The topics of conversation changed frequently, creating a feeling of forced friendship.
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Most hospitalists neither discuss work at home nor actively encourage their children to pursue careers in healthcare.
Many people enjoy the high-stress nature but do not push their children on the same path. Work is seen as a means to an upper-middle class life.
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Everyone wears the same shoes.
Scrubs are more or less standard for nurses. There is surprisingly little coordination among exact similar colors; You may notice a slight variation of blue or purple in their attire. All doctors wear the same standard white coat.
The only clothing option people have is their shoes. Every shoe I saw was either hokas Or onsif anyone believes efficient marketThese should be the most comfortable shoes.
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Being obese is very, very bad.
Not surprisingly, the number of overweight and obese patients I saw was high.
Obesity comes with many practical limitations. Larger beds with stronger motors are often needed, and multiple nurses may be needed to help reposition patients.
One person was too big to fit in the MRI machine and had to be flown to another hospital 20 miles away with a larger machine. This delayed care by more than a day and caused many misunderstandings internally and frustration for both the patient and their partner.
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Patients without close family are the most neglected.
Patients who have multiple family members present, or who cite close family when asked, are the most optimistic and most willing to absorb and act on new medical information from their doctor.
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Security is surprisingly lax.
There were contracted security guards at major entrances, but they conducted only cursory checks. I would classify the level of security as the same as what you would find at a concert.
If you bring a backpack, as I did, it is checked only once before you get a name tag. You can leave and come back with the same backpack and it will not be checked again.
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It’s easy to lose track of time.
Most areas of the hospital are lit entirely with artificial LED light, with no natural sunlight, making it very easy to discern the time of day. The hospitalist I followed compared the hardest part of her job to simply going to work, just as going to the gym is often the hardest part of exercising.
Once you get there, time flies.
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