Things to Come

Robert Chang writes…

In the academic hospitalist world, we’re still in the midst of what is essentially a cultural revolution with significant practical implications.  The continued changes to healthcare and the increasing fraction of work falling to the hospitalist workforce are accompanied by tensions along the multiple interfaces with nursing staff, our colleagues, residents and administration.  After writing my last post, I realized that it may be helpful to give a window into the academic world and the particulars of how I have chosen to prioritize relationships over problems (or failed to do so).  I trust that my experience will not be universally true – hopefully fragments of the story are familiar and help define the issue more clearly whereas other fragments are illuminating due to their contrast with the reality at your institution.
This post will primarily serve as an outline for things to come.

I’ll start with a progression of assertions about how we arrived at the current state of care provided in my health-care system:

a. it is difficult to distinguish our role from a resident’s from the type of work that we do, both for physician and non-physicians
b. much of what is handled by non-physician staff in the community is managed differently in academia (e.g. physician paging, phlebotomy and NGT) – that care is often distributed to the residents
c. the issues that residents traditionally managed without complaint in point b (or at least without voice for the complaint) are now distributed to attending physicians who do complain (sometimes a lot)
d. conflict ensues – between individual physicians and nurses, which breeds a general mistrust and divisions along much broader lines

This is an example of a relatively confrontational view about a fraction of the academic hospitalist world.  Without letting go of this understanding, since there is some measure of truth to it and it allows us to see why conflicts ensues, we also have a chance to remodel the system and how we chose to act in it.  My last post was a microcosm of the division lines that exist and this brand-new opportunity to redeem the ways of old – in the sequence above, the opportunity would be to recognize the common goals that nursing and physicians have and yet that we each have a particular role to play in achieving those goals.

So, in the next several posts, I’d like to look at the dynamics of the following topics and how to move through them in the academic arena:

a. the love-hate relationship between medicine consultants and primary hospitalists
b. the unclear path of promotion for clinical physicians in our institution
c. the joys (yes, joys) of administrating and leading the group I am part of
d. resident and attending interactions
e. where to go with the history of nursing, residents and the introduction of hospitalists

2 Comments

  1. Mike Radzienda on March 24, 2009 at 3:54 pm

    I have come full circle back to academia and love it for all the reasons articulated above. Yes, in private practice hospital medicine we can get a stat Brain MRI with DWI at 9pm on a Sunday and have the results texted to us an hour later. And yes, in academia I have to spend an hour trying to find the feeding tube that should have been stocked in the unit clean supply room, not even consider getting a bottle of Hurricaine spray, sink the tube myself, call x-ray and wait 5 hours for the placement film; then hope the computer isn’t down in order to pull the image on PACS because that stopped printing hard copies last week–didn’t you get the memo?

    In private practice, my favorite surgeon would have had the ex-lap done in the time it took me to find surgi-lube on the academic unit. She would have called me from the surgeon’s lounge to explain the findings in excruciating detail,as well, and sent me a thank you note for the referral.
    In academia….( fill in the blank with the story of your most recent surgical case).
    In this increasingly stressed system, we are on the front lines. I like that. I like the purpose. I like the opportunity for change, the opportunity to create new models of care. The faculty hospitalist asks “why is it broke?” And tries to fix it . In a world where residents just tried to make it through their 30 day block at “County General” and let the next guy deal with the problems, we find ourselves invested and involved (at times for no other reason than self preservation,but hopefully the motivation runs deeper).

    We get to know the nurse on 8 SE and they share a bag of Skittles with us. We’ll buy burritos for the staff on 12 North next Friday. They’ll take a “verbal”from me…..I’ll put the NGT in myself. They’ll settle down the angry wife while I’m trying to do my 10th admit….I’ll put the IV in when the newbie RN is still giving AM meds at noon….

    We have an opportunity to forge new relationships that will redefine the traditional academic contruct.

    Dogs and cats consorting in harmony.

    So lead them.

  2. Robert Chang on April 1, 2009 at 10:20 pm

    Mike,

    Thanks for the interest!

    I agree. There’s something fresh and gritty at being at the front and center. Being at the direct heart of it all, coordinating a crude symphony of resources to help someone with people that you like and know – that’s the earthy realness that just makes hospitalist medicine so great. And the chance to make things work better for patients, colleaegues, nurses, ourselves – just plain old good stuff. Thanks for sharing.

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