Bad to the Bone

By  |  February 26, 2015 | 

I came to hospital medicine from the land of pulmonary/critical care. I had spent ten years dealing with septic shock, respiratory failure and acute renal failure. I had intubated, withdrawn life support, placed central lines, performed thoracenteses, and even placed a couple of chest tubes. I had changed tracheostomy tubes, I ran codes. In short I was a critical care bad ass. I thought I was hot stuff. But I tired of critical care, so I went to hospital medicine.

And died. Just died on the vine.

It turns out that the skill sets necessary for critical care are different from those that are required for inpatient care of general medicine patients. So despite a DECADE of inpatient care in a 24 bed ICU, I was woefully unprepared for hospital medicine. I felt like the stupidest bad ass in the world. Because I was!

I tell you this for a couple of reasons. First, when you are hiring an NP/PA and onboarding them it may seem that their experience in ENT or Urology may have provided them with some skills that they can access and utilize when caring for inpatients. While those experiences will help, it is more likely that they will need a champion to push them up that learning curve, as well as some of that delicious elixir, “tincture of time”.

It is different with physicians in some way. All doctors, when they are hatched from the doctor box of residency, are more similar than dissimilar in the way they approach problems, in their knowledge base, and the way they rely far less on experience than they do on knowledge stores. An NP/PA provider has different experiences, skillsets, education. An experienced NP/PA will take less time to learn than a new grad will, but all will require more time and support than a physician will, INITIALLY. Not to use an offensive example, but just like the differences in development speed between two toddlers, those differences will disappear by kindergarten. Or in the case of an NP/PA/physician about one year.

The second reason I bring this up is because taking care of inpatients is a very specialized skill. The ability to anticipate, prioritize problems and manage the transitions of care is very complex, but more than that it is completely undervalued. I recently was called by a consulting service to admit one of their patients. The man had been having hematochezia for several days and was orthostatic in clinic, his hemoglobin 2 grams below his baseline. I suggested the patient go to the ER for fluid resuscitation before being directly admitted to the medical floor. My concerns were downplayed. Though the conversation was professional I clearly expressed my perspective about admitting what I perceived as an unstable patient. To them the patient “looked fine”. I really don’t think they respected the fact that as a hospitalist I have cared for about a billion GI bleeders in my lifetime. They have not.

We have to make people realize that Hospitalists provide very specific care to complex patients, and we need to help new hires and provide them with the appropriate support and specialized training. That taking care of complex patients is a specialized skill. We are hospitalist bad asses. Or soon will be.

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About the Author:

Tracy Cardin
Tracy Cardin, ACNP-BC, SFHM is the Associate Director of Clinical Integration at Adfinitas Health and also serves on SHM’s Board of Directors. Prior to this, she was the Director of NP/PA Services for the University of Chicago and worked in private practice for a group of excellent pulmonologists/intensivists for over a decade. She has been a member of SHM for over ten years and has over twenty years of inpatient experience, which seems incredible as she cannot possibly be that old! Her interests include integration of NP/PA providers into hospital medicine groups and communication in difficult situations. In her free time, she likes to run and lift, read and write and hang out on the front porch of her semi-restored Victorian house with her dear family and friends while drinking a fine glass of red wine and listening to whatever music suits her whimsy.


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