Dear hospitalists, we emergency physicians appreciate you

Dear hospitalists, we emergency physicians appreciate you

Dear hospitalists,

This is just a note to say that we, in emergency medicine, appreciate you.  Like all of us, you are stuck in an endless loop of unending residency.  Don’t worry, it isn’t an episode of The Twilight Zone.  It’s just your life.  No, it’s our life!

As specialty after specialty withdraws from the practice of medicine, you, and all of us, are left holding the bag.  We’re the college wing-man, sitting at the table with the hot girl’s weird friend.  That is, the rest of medicine skimmed off as many normal, paying customers as possible, and the rest of them were granted graciously to us.

We feel your pain.  Heck, we administer your pain. But not because we have any options really.  Every neighborhood clinic that has a slightly sick patient sends them to the ER.  Each and every nurse’s aid or home-health worker who notices a blip in blood pressure, a faint murmur or something black or red in a body fluid sends their charges our way.  Every family medicine office or urgent care that feels beyond their capacity, or is approaching closing time, tells the patient to go to the ER.  Sometimes they call, sometimes they don’t.  But “go to the ER” is one instruction that they always follow.

So, when they arrive at our door, some of them are actually sick!  The nerve!  At that point, either their physicians have astutely chosen to surrender hospital privileges in exchange for more money and time off, or they don’t have a physician at all.  And so, when the work-up is done and it becomes clear that discharge is no longer an option, we ring you brave lads and lassies.

We recognize the empty souls behind your tired eyes as you admit the 105 year old dementia patient with, yep, weakness.  Your tenth admit for weakness in 12 hours.  We know that the average age of all your admissions is somewhere around 85.  We hear your souls die a little when we say, “the family wants to put him in a nursing home and says he’s more confused than normal.” It’s sad to hear you sobbing to yourselves over the phone, wondering why you didn’t study just a little harder and become an ophthalmologist.

But we know it hurts in other ways.  It hurts when you have those days.  Those days when you have all the same patient.  Eight chest pain work-ups.  Six Xanax overdoses.  Nine TIA’s.  Seven syncopes.  And a partridge in a pear tree. The thing is, we see them before you do, and we understand.  We just realized, early in our career, that two hours of anything was more than enough.  You have them for days.  Bless your hearts!

We also feel for you when it comes down to the patient dumping contest.  You know, the ancient hip fracture with 26 meds whom the orthopedist says, “have the hospitalist admit them, we’ll consult.”  The GI bleed, of whom the gastroenterologist says, “have the hospitalist admit her, we’ll consult.”  The nosebleed on Coumadin dodged by ENT and gifted to your capable hands.  The post-op cellulitis, the post-partum pneumonia, the vague abdominal pain.  “Have the hospitalist admit them.”  The very words must haunt your nightmares, as assorted specialties leave the annoying work, the admission orders, sliding scales, pain meds, dispositions, social planning and midnight phone-calls … to you!

Sure, we have our differences.  I have nothing to offer the patient who refuses to go home, and you can’t admit them or you’ll be hauled off to Medicare prison and water-boarded by government functionaries.  We have our tiffs.  But the thing is, we’re BFFs. We’re soul-mates.  We’re “brothers by another mother.”

Medicine keeps getting harder.  And fewer and fewer folks are doing it.  America has no idea that the weight of it all is falling upon the shoulders of the emergency physicians and hospitalists who lurks inside the trauma rooms and inpatient floors, the fast-tracks and ICU’s of their community and university hospitals.  The pasty-pale, coffee-sucking, junk-food eating Spartans of health-care, who will bear the full Persian assault of health-care reform when there aren’t enough primary care doctors to manage an AARP convention, much less all of America.

So let’s stick together, shall we?  In point of fact, we might need to form an organization, a common political advocacy group.  If nothing else, a fraternity.  Tau Iota Lambda Mu … Take it like a man.

Bottom line, hospitalists, we respect you and we need you.  So don’t get mad when we call you.  Just think of it as a little note from someone who, for assorted reasons, understands you.  Someone who “gets you.”  And someone who has already endured the same patient and has simply run out of ideas.  And has to go home at the end of the shift …

Hospitalists, we heart you!  We’ll have your coffee waiting.  The hematologist says that the grandma in Room 8 has ITP. Call him if you need him.

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of The Practice Test.

Image credit: Shutterstock.com

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  • http://www.facebook.com/Cheryl.A.Handy Cheryl Handy

    Dear Hospitalists – we, the patients and patient families are the ones that bear the brunt of your weariness. We can tell you don’t want to treat grandpa.

    The majority of us do not “patient dump.” The majority of us are just as tired and frustrated as you that grandpa needs to be re-admitted. The majority of us stay by grandpa’s side during the hospitalization, sleep in uncomfortable chairs net to grandpa every night. We know more about grandpa’s condition that you. Wouldn’t it be useful to listen to us?

    We wish you would contact grandpa’s primary care giver and treating physicians so that you can learn about grandpa’s whole medical condition. However, in many instances, hospitalists are in hospitals to triage only the current presenting condition. Hospitalists say they are tasked with lowering costs for the hospital. Hospitalists even say contacting grandpa’s treating physicians would “muddy the waters” of the triage and stabilize task.

    Don’t you care that last week grandpa had a urology procedure to reduce his prostate? Wouldn’t it help to contact grandpa’s urologist? Maybe a UTI is causing the confused mental state. A simple dip stick urine test may not detect the UTI. Why not perform a real urine test for cultures? Is grandpa too old to justify that test?

    Don’t you care that grandpa had orthopedic surgery several months ago on his foot and now there is a oozing hole at the surgical site? Wouldn’t it help to contact grandpa’s orthopedic surgeon?

    Don’t you care that grandpa just finished a round of chemotherapy? Maybe the cellulitis and altered mental state is because of infected cellulitis. Wouldn’t it help to contact the oncologist?

    We are sorry you are tired Dr. Hospitalist. Patients and their families are tired too. Many of us lose nights of sleep to care for our loved ones. And we know if the hospitalist merely triages the current presenting condition and discharges without considering grandpa as a “whole medical issue” then grandpa will be readmitted sooner rather than later.

    Dr. Hospitalist, don’t recommend a nursing home when the patient’s family is caring for grandpa. We patients and family members know that nursing homes are the being of the end for grandpa.

    We are sorry grandpa is old and grumpy. He doesn’t feel well. He is scared of dying. Grandpa knows you don’t want to treat him, Dr. Hospitalist. He’s sorry he bothered you and he is grateful for whatever you can do to alleviate his pain and suffering.

    • southerndoc1

      The current system is not intended to work for either patients or physicians: it is designed to work for insurers and corporate interests.
      Your sarcasm and resentment are misdirected.

      • N N

        Don’t be surprised by Cheryl Handy who is a medical malpractice attorney (Google her). It’s any wonder doctors are leaving primary care in droves bc of misdirected drivel like this.

        • ninguem

          I took your advice and Googled.

          Not even a very successful attorney.

          • http://www.facebook.com/Cheryl.A.Handy Cheryl Handy

            Actually, before I got sick, moved from IL to NC to care for dying dad, I was successful. I helped create the IL law that makes it illegal for corporations to practice medicine.

            Attacking me doesn’t change facts.

            I lived the hospitalist nightmare as a cancer patient (when I was hospitalized and the hospitalist never told my oncologist I was in the hospital) and the nightmare of hospitalist telling me that contacting my elderly dad’s oncologist and treating physicians would “muddy the waters” of triaging him. He died because hospitalizes didn’t want to “muddy waters.” Hardly “drivel.”. And I didn’t even sue.

            (And I am not even getting into the muck of the fact a bad orthopedic surgeon in IL crippled me in 2000 and caused me to be depressed).

        • http://www.facebook.com/Cheryl.A.Handy Cheryl Handy

          Umm. I am not (and have never been) a medical malpractice attorney. I am not even a licensed atty. I stopped practicing law when I couldn’t keep up with my law practice (depression, cancer). I did practice medical malpractice *defense* when I was a licensed attorney. After my bout with invasive cancer, I cared for my dad 24/7 while he had cancer and osteomyelitis. Now I am a patient advocate who believes in @sorryworks.

      • http://www.facebook.com/Cheryl.A.Handy Cheryl Handy

        It is the fault of the medical system that “the current system is not intended to work for either patients or physicians.” My post is not sarcastic. It is honestly what patients deal with everyday. If physicians are working for patients then they should get out of the profession.

      • http://www.facebook.com/Cheryl.A.Handy Cheryl Handy

        I certainly wasn’t sarcastic. I was honest and heart-felt. I understand that the new normal has eroded the traditional, all important physician-patient relationship.

        It is amazing to me that physicians no longer consider patients as their primary focus and duty. Instead, according to health care social media and technology experts, physicians first owe duty to (1) themselves, (2) the employer, (3) the insurance company, (4) the government, (5) any dme supplier or pharm for whom they are consultants, (6) stand alone MRI or other entities for whom they have financial interests. The patient is way down the line.

        My resentment is that the new normal marginalizes the physician-patient relationship. Patients are expected to accept hospitalists, NPs, NAs, etc as their “medical care provider” in some bifurcated medical “community” where patients are now considered “consumers.”

        Physicians should be more angry. They are being pushed out of the health care system. Physicians are now (thanks to govt) interchangeable commodities in the healthcare system.

        • southerndoc1

          You’re speaking to the choir. Patients and physicians are losing this battle.

    • drdoctormd

      Now that’s how you hijack a thread!

      • http://www.facebook.com/Cheryl.A.Handy Cheryl Handy

        Hardly hijack. My comments are valid and important to the issue of hospitalists.

        • drdoctormd

          Nobody said your comments are invalid or unimportant. In fact I wish you and your grandfather had the opportunity to have been cared for by me or one of my hospitalists. Your experience sounds terrible.

          This article is a sort of tongue-in-cheek jab at hospitalists and ER docs, while attempting to make some between-the-lines commentary about the state of things. As a hospitalist it stings a little, but it definitely rings true. You’ve chosen this forum to rant on and on about something that many people would tend to agree with you about. Your story and your comments feel more like they should be posted on a blog of your own. Here it feels misplaced in reference to this article.

          And yeah, posting more words in responses than the original article contains that didn’t really ask any questions…that’s sort of what hijacking means.

          • http://www.facebook.com/Cheryl.A.Handy Cheryl Handy

            Didnt mean to hijack. Never heard that rule about word/length.

            I have blog. But the change in the hospitalist program model needs to come from docs who care enough to protect the integrity of the profession.

    • kjindal

      just more evidence that lawyers are just not that bright. If you (or more likely, your undereducated lottery-mentality obese tattooed-up-the-wazoo client) cares so much for grandpa, than take the initiative and maintain his records from the multitude of specialists and procedures you’ve put him through in his old age. medmal lawyers are the bottom of the barrel, below plankton. Your bullshit charade of caring so deeply for grandpa is so transparent, you should be ashamed, but are too stupid to see it.

      • http://www.facebook.com/Cheryl.A.Handy Cheryl Handy

        Grandpa was my dad. And I did have all the records. The “busy” hospitalist canceled all of the tests the terrific Duke residents wanted to do. The hospitalist told me contacting the treating docs would “muddy the waters” because her job was to triage, stabilize and discharge. I even called the treaters myself but they can’t get past the hospitalist.

        I slept every night in a chair and watched my dad suffer.

        Dad was a cancer patient. I went directly to the Duke oncology clinic and begged for help. The NP came to Duke hospital and tried to help. But it was too late.

        Dad had a wound where he had orthopedic surgery. The hospitalist ignored dad’s open sore. It turned out to be osteomyelitis. Dad died from that oversight.

        The major issue is that there is no standardization in the hospital program model. Some hospitalists may be awesome. But is the hospitalist merely wants to triage, stabilize and discharge then the patient will likely return.

        Insulting patient’s families (like me) is typical of the new trend in medicine. Patients and their families are the enemy.

  • ninguem

    The family docs were pushed out of the hospitals. Service by service, the primary care docs got one procedure, service unit after another taken away.

    No obstetrics, no ICU, no nursery, on and on and on, until it wasn’t worth staying

    • http://www.facebook.com/profile.php?id=662132748 Lata Potturi Schaedler

      Spot on.

  • drdoctormd

    This is funny. We’re kindred spirits, Hospitalists and ED docs, huh? Like the co-Vice Presidents of the D & D Club. Appreciated but not even popular enough among geeks to be the President…wait maybe I’m revealing too much?

  • Benita Kurtzman

    ER doctors take care of patients with emergencies and hospitalists take
    care of patients in the hospital. It is unreasonable to expect a
    gastroenterologist to admit and care for the unrelated needs of a
    patient with a GI bleed, while tending to their office practice and
    procedures. That is the reason these specialties exist. It sounds like
    the author wants to sit around and collect a paycheck while all the
    other specialists do their job and add primary care to their specialty.
    This article is pretty shameful and I only hope the author adjusts his
    attitude.

  • http://www.facebook.com/profile.php?id=1536821513 Edwin Leap

    Dear Benita, This article was meant to reach across the aisle, as it were, and build camaraderie with another group of physicians. I’m not really sure what attitude I should adjust, and I’m certainly not clear where you get the idea I just want to sit around and collect a paycheck. (Of course, I do, but I’m willing to work for it.) The problem is, increasingly I end up caring for chronic problems for which I’m not the best physician. And I end up being the only portal into the hospital, since family docs often don’t admit and hospitalists are leary of direct admits they don’t know. However, that’s neither here nor there. Benita, like so many who comment here, you seem to be looking for offense. That’s not what this is about, but if you must be offended, feel free.

    • N N

      “It’s sad to hear you sobbing to yourselves over the phone, wondering why you didn’t study just a little harder and become an ophthalmologist.”

      “We just realized, early in our career, that two hours of anything was more than enough. You have them for days. Bless your hearts!”

      “And someone who has already endured the same patient and has simply run out of ideas. And has to go home at the end of the shift”

      Reaching across the aisle? Yes, reaching across the aisle to twist the knife.

    • drdoctormd

      I got it, Dr. Leap. I might be the only one who did. Sarcasm and self-deprecation as humor. Look it up folks. It was humorous.

    • kjindal

      this article certainly does ring true to me, and is well-written and seemingly heartfelt. I, for one, feel tremendously guilty when I send an elderly demented patient to the ER for “weakness” at the behest of unrealistic families.

      • http://www.facebook.com/Cheryl.A.Handy Cheryl Handy

        What would you propose to say to the families? These families know the elderly patient and his medical history better than a doc who has never seen him/her.

        Do you docs even like patients?

        My dad had severe upper UTI. He was not demented. His urologist told me that often the only presenting symptom for upper UTI is altered mental state. I couldn’t get a ED or hospital doctors to run urine cultures. I was told by hospitalizes that urine cultures were to expensive to run. They would only run a urine dip stick (that showed no UTI).

        It wasn’t until dad was discharged and I drove him to the Duke clinic urologist that cultures were taken and infection found. Dad was placed on abc.

        • kjindal

          what i would say, and DO say all the time, is for someone who is bedbound, noncommunicative or similarly incapacitated, let’s try our best to evaluate and treat IN PLACE e.g. outpatient or nursing home, and NOT hospitalize. The hospital is a BAD place to be, albeit sometimes necessary in the context of predicted improvement in status. For the multiply-comorbid debilitated elderly patient with altered mental status, it is eminently reasonable to evaluate and try one’s best to manage as outpatient, even if the workup does not proceed as emergently or quickly as compared to a hospital.
          And I love my patients & their families (my setting is a large nursing home, with extensive support for IV treatments, xrays, labs, etc., all without hospitalization or ER transfer). However too often I see unrealistic families who insist on grandpa going to the ER for a fever, when he’s been bedbound, PEG-fed, & completely noncommunicative for 5 years.

          • http://www.facebook.com/Cheryl.A.Handy Cheryl Handy

            FYI – I was never “unrealistic.” I kept dad out of ERs and hospitals – unless his oncologist demanded.

            Great example of “bad hospitalist” – dad was at oncologist and had horrible cellulitis. It was painful, smelled foul, oozed. Oncologist had him admitted to Duke Hospital directly from Duke Oncology with the order that dad get 3 days of IV antibiotics.

            Unfortunately (bc I typically stayed with him in hospitals), I was out of town on business for those 3 days. When I returned, dad had been in Duke hospital 3 days, had the same bandages on that *I* put on and the Duke hospitalist said dad didnt need any antibiotics.

            I took him home, returned to Duke oncology the next day (a Friday) and oncologist & NP were shocked. The oncologist thought dad was getting IV antibiotics. They prescribed oral abx, taught me how to care for wounds and prescribed pain medications.

            I returned dad to Duke oncology 3 days later (a monday). Dad’s oxygen was dangerously low. He was readmitted to Duke Hospital with pneumonia and infectious cellulitis that progressed to osteomyelitis.

            Dad suffered (ultimately died) bc the Duke hospitalist did not communicate with Duke Clinic oncologist.

            I gave up my life in Illinois to care for my dad in NC. I didn’t abuse the medical care system. He was never communicative. He knew when he was dying and we talked about it.

            I took dad to all outpatient appointments. He didnt need a nursing home.

            Shame on doctors who blame families for bringing sick, elderly parents to the doctor. My only (realistic) expectation was that Duke hospitalists communicate, coordinate, cooperate with Duke Clinic treating physicians.

          • kjindal

            Firstly let me emphasize that I am not “blaming” anybody, and am sorry your father was sick and ultimately died. And obviously I don’t know the specifics of his care except what you have presented here. But let me also point out the following:

            a) perhaps he would’ve fared the same whether he got IV, oral, or NO antibiotics?

            b) the oncologist & his NP could have contacted the hospitalist (who is likely much much busier) rather than vice-versa.

            c) the oncologist could’ve cared for your father directly himself in the hospital, rather than deferring to the hospitalist. It’s hypocritical to say “i’m going to send your father to the hospital for IV antibiotics” and then not either manage the case yourself or present the situation to the caring MD overtaking care (ie. the hospitalist).

            d) maybe your father died because (again I am sorry & not trying to sound insensitive) he was old, sick, and had cancer. Cancer patients always die of something, whether it’s pneumonia or some other infection leading to sepsis, or the stress on various organs from chemotherapy / radiation /etc. Technically cancer itself rarely kills anyone, but bad things that happen to old people do happen with greater frequency & severity in cancer patients. I was an oncology fellow once, and saw this everyday.

            In my experience too many outpatient doctors & midlevels expect too much LONGITUDINAL care in the inpatient setting, where actually the role of such a setting is exactly to triage, treat, and discharge; the longitudinal care you expected from the hospitalist should’ve been deferred to the primary team (in your case the oncologist & his NP)

          • http://www.facebook.com/Cheryl.A.Handy Cheryl Handy

            (a) No, he needed the IV antibiotics. When he was re-admitted (at a different location of Duke Hospital), he was put on abx and cellulitis resolved. In fact, pneumonia resolved after 5 days of another unfortunate inpatient stay.

            (b) Yes. Great point. The communication between hospitalist and clinic docs is a two way street.

            (c) At Duke Hospital, the Duke clinic docs *must* hand off to Duke hospitalists. That means (as Duke administrators and hospitalists tell me) Duke clinic docs and even Duke ED docs have no authority to care for their own patients once admitted. The clinic docs can’t even order tests.

            (d)Dad actually initially beat colon cancer. But Duke Hospital radiologist emailed to Duke oncologist that Dad had small lesion on liver that could be easily ablated. Unfortunately emails between Duke Hospital and Duke Clinic docs don’t make it to medical records. No one who treated Dad knew about the ablation recommendation. Months later, cancer came back in liver.

            But ultimately Dad died because chemotherapy and orthopedic surgery (Dad got surgery for fallen arch after cancer initially resolved). Dad developed osteomyelitis. Duke oncology, Duke infectious disease and Duke orthopedics never communicated about the osteomyelitis. OM went septic.

            ps. to docs that dismiss or “hate” me — I never even thought about suing Duke regarding Dad’s care. All I beg for is better communication, cooperation and coordinate of care between hospitalists and clinic docs. Just communicate. I know he’s old. But, I am the primary 24/7 caregiver. I just need a team to work with so that I can give him care at home.

            The day Dad died he wrote his name on a sheet of paper. Dad handed it to me and said that he could “go on the boat” today. He told me to give the paper to someone when I “get there” so an angel could find him for me. I asked Dad whether he wanted to go to doctor. He said no. He was still coherent and making sense. I laid Dad in bed. He spoke with Mom and they talked about how they loved each other. He made me promise to care for Mom. He asked me if he could go. I said yes. Dad passed away in his sleep.

            I didn’t unrealistically bring Dad to ED or any doctor to expect some miracle. I didn’t “bother” any doctors time.

  • Jennifer Dear

    Who says those that don’t admit patients to the hospital no longer “practice medicine”? How is a hospitalist’ life ANYTHING like residency? I didn’t get to work 7 days on and 7 days off, did you? And don’t get me started about whether or not the PCP called the ER when they sent their patient over – 9 times out of 10 you would never guessed I called based on the ER documentation and disposition. Don’t get me wrong – I appreciate the work hospitalists do but I don’t consider it more noble than outpatient primary care and let’s not forget THAT’S THEIR JOB. They signed up for it.

  • Benny Little

    I’ve been in multiple hospitals with multiple co-morbidities and have never met an uncaring hospitalist. I’m sorry Cheryl Handy had a bad experience with her hospitalists, but it is not the norm.

  • gthang009

    As an internal medicine subspecialist, I have ran across a number of emergency room physicians, and I really have to say they must be the most incompetent of all physicians. I understand that there time is limited, to deal primarily with acute issues, but good triage and ed nurses would probably suffice. The majority of the time emergency physicians spend on is disposition, trying to dump patients to the hospitalists, as opposed to thinking through a patients condition, and determining appropriateness of admission.

  • mr. 6&8

    perhaps this is a problem with the”model” I am a sub-specialist and when I get a patient with multiple problems including one of my own, I call the E.R. doc to let them know the patient is coming and the hospitalist to admit if needed. The hospitalist is HAPPY becuase he/she (partners) are in private practice and this is how they make their living. Astonishingly, they say THANK YOU for every patient, and not sarcastically. I ask them point blank, Do you feel like you are my resident? They laugh and say “bring it on”. This is a huge difference that happens to employed physicians…it is only human nature.

    • http://www.facebook.com/Cheryl.A.Handy Cheryl Handy

      The problem from my perspective is that there is no standardization in the Hospital Program Model. The standard of care should be that hospitalists and treaters work together. It shouldn’t be the exception to the rule. It shouldn’t happen “sometimes” or “at my hospital.” Communication, cooperation and coordination between hospitalists, clinic and ED docs must be required. It must be a standard of care for the sake of patient care and transition of care.

      No slam against Duke University Hospital. But, if the Hospitalist Program Model does not mandate such communication at a prestigious institution like Duke, then where else are patients at risk? Doesn’t institutions like Duke butchering the Hospitalist Program Model trouble hospitalists?