Hospital Medicine Community: How do we instill some order into the daily chaos? – Part I

Several years into my career in hospital medicine, I have to say that I still enjoy my job as much as ever and have absolutely no regrets in choosing this profession. I firmly believe that at its best, being a hospital doctor is one of the most rewarding jobs anyone could ever hope to have. You are the “captain of the ship” utilizing your skills to treat patients’ complex illnesses, guiding them through their hospitalization. You get to form very close relationships with patients and their families as you strive to get them better. Having worked in several hospitals up and down the East Coast, I’ve been fortunate enough to work mostly in supportive environments where I’m afforded the opportunity to do this to the best of my abilities.

However, I know that many in our specialty across the country work in situations less conducive to optimal patient care. The truth is that all nostalgia aside, it’s an unfortunate fact that our specialty is not as popular as it could be and suffers from a notoriously high rate of turnover, burnout and career fatigue. Why is this and should we just accept it as a given?

Having close experience of different types of group and talking to dozens of colleagues, I believe that the main reason is quite simple: it’s nothing to do with the actual job itself, but the fault of the environment in which we perform the work. In a large number, if not the majority of hospitals, the practice of hospital medicine is simply too chaotic and disorganized. On any given day, as the doctor tries to get through their patients, there will be frequent interruptions by the emergency department, nurses, the pharmacy, case managers and others—all while the doctor is attempting to talk to a patient and their family, write a patient note, or put in an order. Leaving aside any other issues regarding administrative or financial complaints, I would like to identify this as the single biggest issue facing us.

This constant interruption – stopping and starting of tasks – happens much more in hospital medicine than in any other specialty and seems to be universally accepted as the way things have to be. But does it really have to be this way? The sheer volume of interruptions to workflow and multitasking requirements can seem overwhelming and is unhealthy for both the physician and the job that’s trying to be accomplished. On a busy day, it can be a uniquely difficult situation to work in. Don’t get me wrong—I’m not complaining by any means (personally I’m actually a glutton for running around and multitasking)—but merely stating the realities of the daily job as I see it for a lot of us. It’s precisely because I love hospital medicine that I want all my colleagues to have higher job satisfaction. Remember, this isn’t cutting cookies—one error, and someone’s life is on the line. There’s been a lot of talk recently about patient safety and the comparison between aviation and healthcare. Imagine if a pilot had to regularly work in such a chaotic situation. I for one certainly wouldn’t want to fly!

I once worked with a locum per-diem colleague who turned around to me one day and said, “You know there’s nothing wrong with being a hospitalist, but most groups out there are very poorly managed.” That hit the nail on the head. Over the years, I’ve also heard other statements that really made me reflect on our specialty:

· I remember a promising resident telling me that she didn’t want to do hospital medicine because she felt the job was “all about multi-tasking” rather than actual medicine (how disappointing that we’d given her that impression)

· A colleague once said to me that every day is “like groundhog day”

· A friend who is a cardiologist told me how himself and his colleagues thought that most hospital doctors in his (very large Massachusetts) teaching hospital “seemed like they really hate their jobs” and were running around like headless chickens

· A specialty colleague remarked to me one morning, “I don’t know how on earth you can do this. You are getting called and paged from all directions at the same time about admissions, discharges and urgent floor situations!”

· Another promising resident threw a question at me as we finished rounding; “Hospital medicine seems okay, but what are your plans afterwards?”

· Too many to count nurses telling me off the record that they think members of our team seem unbelievably stressed during the day

I feel a bit sad when I’ve heard statements like these. Because at it’s best, I know how awesome hospital medicine is capable of being. The even sadder fact is that it’s not just the individual doctor who loses in a bad work environment—but also the whole hospital and ultimately the patient. And herein lies the problem. From what I’ve seen, the assumption is that our specialty has to be chaotic, stressful, monotonous and dare I say it “resident-like” (we’ve all heard that jibe). Worse still, as that last statement shows, lots of people just view it as a stop gap to something else.

Tune in tomorrow to The Hospital Leader when I discuss some solutions to finding order in the chaos that currently characterizes hospital medicine.