#MomInHospital

A few weeks ago, a middle-aged man decided to tweet about his mother’s illness from her bedside. The tweets went viral and became the subject of a national conversation. The man, of course, was NPR anchorman Scott Simon, and his reflections about his mother’s illness and ultimate death are poignant, insightful, and well worth your time.

Those same days, and unaware of Simon’s real-time reports, I also found myself caring for my hospitalized mother, and I made the same decision – to tweet from the bedside. (As with Simon’s mom, mine didn’t quite understand what Twitter is, but trusted her son that this was a good thing to do.) Being with my mother during a four-day inpatient stay offered a window into how things actually work at my own hospital, where I’ve practiced for three decades, and into the worlds of hospital care and patient safety, my professional passions. In this blog, I’ll take advantage of the absence of a 140-character limit to explore some of the lessons I learned.

Screen Shot 2013-08-17 at 5.00.57 PMFirst a little background. My mother is a delightful 77-year-old woman who lives with my 83-year-old father in Boca Raton, Florida. She has been generally healthy through her life. Two years ago, a lung nodule being followed on serial CT scans was diagnosed as cancer, and she underwent a right lower lobectomy, which left her mildly short of breath but with a reasonably good prognosis. In her left lower lung is another small nodule; it too is now is being followed with serial scans. While that remaining nodule may yet prove cancerous, it does not light up on PET scan nor has it grown in a year. So we’re continuing to track it, with crossed fingers.

Unfortunately, after a challenging recovery from her lung surgery, about a year ago Mom developed a small bowel obstruction (SBO). For those of you who aren’t clinical, this is one of life’s most painful events: the bowel, blocked, begins to swell as its contents back up, eventually leading to intractable nausea and vomiting, and excruciating pain. Bowel obstruction is rare in a “virgin” abdomen – the vast majority of cases result from scar tissue (“adhesions”) that formed after prior surgery. In my mother’s case, of course, we worried that the SBO was a result of metastatic lung cancer, but the investigation showed only scar tissue, probably from a hysterectomy done decades earlier.

The treatment for bowel obstruction is to place the bowel at rest (“NPO”) and to suction out the contents of the stomach through a nasogastric (NG) tube, which decompresses the GI tract and decreases the pain and distension. And then you wait. Many SBOs will open up on their own, but those that don’t after a reasonable waiting period (4 to 7 days, generally) require surgery. Mom’s first obstruction didn’t open up, and a mercifully uncomplicated laparoscopic procedure successfully cut the fibrous band that was kinking the bowel (“lysing the adhesion”), relieving the obstruction.

Unfortunately, she had two more cases of SBO in the next year; these resolved after 3 to 5 days of bowel rest without surgery. We hoped we had seen the end of it, but we hadn’t: on a visit last month to the Bay Area to see my sister and me, my mother developed another SBO, a few hours before getting on the plane to Florida. Her pain began slowly, but within an hour she was in agony, retching, sweating and literally shaking. (By the way, nothing prepares adult children to see their parents in this much distress; it seems so very wrong, the world turned on its head. One of Scott Simon’s tweets captured my feelings: “I wish I could lift my mother’s pain & fears from her bones into mine.”) I took her to UCSF Medical Center’s emergency department. The next day, I sent my father – who is becoming a bit frail and whose presence by the bedside of his wife of 59 years was likely only to make everyone more anxious – back to Florida.

I’ve “eaten at my own restaurant” many times before: my two sons were born there, I’ve had surgery there, and I’ve accompanied family and friends to a dozen or so ED visits over the years. But being there with Mom somehow felt different: first of all, it was my mother; second of all, her hospitalization was likely to last several days (culminating in either resolution of the SBO or surgery), with brief periods of excitement punctuating long periods of waiting. This offered me the chance to soak in the processes and the culture. Here are six lessons I drew from my observations:

Chokepoints: One of the key principles in “Lean thinking” is to identify steps in a care process that don’t add value. Within a few minutes in the ED, I found a doozy. There was little question that Mom was having another bowel obstruction and, just as clearly, was going to end up with an abdominal CT scan. The scan has become trivially easy to do: there’s a scanner in the ED, and the test now takes about 10 minutes to complete. Blood tests were drawn and some results, such as the CBC, returned quickly. A few minutes after the blood was sent to the lab, the radiology tech arrived to obtain a chest x-ray and KUB (two different x-rays). Why did she need these, I wondered, when she’s going to get a CT scan in a few minutes?

It turns out that even a “stat” creatinine takes an hour or so to return, and radiology, understandably, won’t do a CT scan with contrast in the absence of a recent test of kidney function. Given the small chance that Mom was suffering from some other abdominal catastrophe like a perforation, the ED docs felt that an hour’s wait for the CT was too long. And so came the stat KUB/CXR – at a cost of several hundred, perhaps even one thousand, dollars – all because the creatinine was not more promptly available. It made me wonder: has anybody done the accounting to figure out the cost of a more rapid creatinine assay, factoring in the savings (in dollars, motion, and radiation) from obviating the need for the other, inferior, studies? And how many other chokepoints like this are scattered around our system?

Introductions and Rounding: On our medical service at UCSF, we’ve worked hard at improving the way we introduce ourselves, and my experience with Mom made me glad of this. We now have a whiteboard by each bedside, on which all of the players (attendings, residents, students, nurses) are supposed to write their names, although adherence is less than perfect. Moreover, all our physicians now hand patients “face cards” with our pictures, names, titles, education, and a description of our role.

On Mom’s surgical floor, while the nurses and patient care assistants (PCAs) were excellent at introducing themselves and writing their names on the whiteboard, the doctors were not. Some didn’t introduce themselves at all; most did, but their roles were unclear. There were no face cards, and no physician names on the whiteboard. While the physicians in the ED did a good job introducing themselves, once we made it to the surgical ward, it was more than six hours before we had any idea who her primary doctor or team were. Later, when they came in to see her, they left behind no written traces.

We need to standardize, and then modernize, this effort. Sure, let’s start with cards and whiteboards. But how about this for an ideal futurist scenario: when doctors or nurses enter a room, our badge automatically triggers our picture, bio, and position description to pop up on the patient’s television screen or tablet computer, all recorded so that they can be shared with family members and looked up later.

Which brings me to rounding practices. On UCSF’s pediatrics inpatient service, teams now prospectively plan their morning rounds and – are you sitting down – produce a schedule that tells patients and families when the team will be by to see them. This schedule allows the nurse to be there, as well as some of the relevant subspecialists. We’re currently trying to figure out if we can pull this off on our much bigger and more geographically scattered medical service. I will push for us to do so, particularly after my experience with my mother.

I knew the surgeons would be there at some point between 6:30am and 9am, but had no way of pinning down the time beyond that. (Think about how you feel when Comcast says that the cable guy will be there between 1pm and 5pm.) I also knew that once the surgical team members left the floor, I would have no further access to them for the rest of the day. Most mornings, I came in by 6:30 and waited. One morning, I got there five minutes late, but luckily caught them before they left the ward. And one morning, I missed them and, as Murphy would have it, that was the occasion for the worst error of the hospitalization.

(Far) Too Much Information: On the morning I missed the surgeons on rounds, I had given myself a treat, stopping at Starbucks on the way in to the hospital. While sipping my mocha, I received a frantic call from my dad in Florida. “One of the doctors was just in to see your mom, and told her she has lung cancer,” he said, his voice shaking. I’m on my way in, I told him.

You can guess what happened. A harried July intern was running from room to room seeing patients, her mind probably distracted by the thoughts of everything she needed to get done that day. She saw the official reading of the abdominal CT scan from the prior day. On it, Mom’s left lung nodule was seen and called “suspicious for malignancy.” (Her prior films are in Florida; the UCSF radiologists had nothing to compare this to.) Rather than calling me about the finding (yes, everyone knew who I was [though I remain unconvinced that VIP status necessarily improves one’s outcomes] and my cellphone number was on the whiteboard), the intern came into Mom’s room, woke her from her morphine-aided sleep, and told her that the x-ray showed probable lung cancer. My mother wasn’t sure if she had dreamed this. Unfortunately, she hadn’t.

I was livid, but now have the distance to draw some general lessons from this error:

  • The word “cancer” remains emotionally nuclear; it should not be tossed around lightly.
  • Don’t give weighty, complex, and highly charged information to narcotized elderly people – or anyone for that matter – who are just waking up without having their family there.
  • The intern should have made a little effort to inquire about prior films.
  • We really need interoperable health records, which would have allowed our radiologists to access Mom’s Florida scans.
  • Even when you’re rushing through your checklist, please use a little common sense.

The Nurses: I’ll not be the first person to observe that it is the nurses, not the doctors, who really determine the overall experience of a hospitalization. Our nurses, on 13 Long at UCSF Medical Center, were exceptional. The nurses and the Patient Care Assistants (PCAs) were competent and caring, and they had their acts together. In the old days, our nurses wore varying types of clothes, the roles of nurses and PCAs were vague, and basic processes like medication administration and shift change were done haphazardly. Today, UCSF nurses are dressed professionally, in uniforms that make clear their roles; their handoffs are robust (“I’m signing off in 30 minutes; this is Anna, who will be taking over for me”); it’s clear what the nurses do and what the PCAs do (there is a special place in heaven for the PCAs, by the way); and the presence of bar coding and computers in the rooms makes things feel far safer and has standardized previously chaotic processes. (All of these elements are captured by our achievement of “Magnet Status.”) One nurse tried an IV twice, couldn’t get it, and calmly said, “I wasn’t successful; I’ll get my colleague who will get it done.” (She did.) And everybody cleaned his or her hands, every time. It was very impressive.

Part of the reason that the experience with the nurses is so important is that it either does – or doesn’t – give you as a family member trust that things will be okay when you’re not there. When Mom was hospitalized in Florida last year, my father hired a private nurse to be with her one night; on another, I asked to sleep at her bedside, and was given a cot so disgusting that it would have been rejected by every youth hostel I stayed in during college. At UCSF Medical Center, I left at 10pm each night with complete confidence that things would be okay overnight.

Yet there are nursing-related processes that can be improved. Two bits of technology remain the bane of patients’ lives in the hospital: the nurse call button and the IV pump alarm. In 2013, in a hospital in San Francisco, can we really not come up with a system where the call button triggers a video feed to allow a nurse to see and speak to the patient, allowing for effective triage? And the IV pump beeps incessantly: kinked line, empty IV bag, incoming tweet, who the hell knows. Isn’t there some new technology to improve this situation?

(Speaking of new technology, the NG tube also seems ripe for innovation. Rigid and uncomfortable; it gives poignancy to the old schoolyard insult, “up your nose with a rubber hose.” Can’t we do better?)

Jargon: Boy, this one is tough. I’ve got a pretty good jargon detector, but after watching the docs speak to Mom for a few days, I realized that half of what I say is probably unintelligible to my patients. One of the surgeons, who I regard as a fabulous communicator, came in one day to talk about Mom’s surgical options. “We can go in there and try to lyse the adhesions, but this only will work if we can find a focal lesion,” he said. Not the worst I’ve heard, but listening through my mother’s ears, I realized that she did not understand anything after, ‘We can go in there…” On our rounds, perhaps we should appoint one team member to be our official jargon-detector, offering the speaker feedback in an effort to sensitive all of us to this pernicious problem. (Sure, the patient-centered view would have us empower patients to speak up if they don’t understand something, but I think few patients will. Certainly not my mom – unfailingly polite, she just shook her head in agreement, despite understanding very little).

Managing Uncertainty: Because of my VIP status, we had a lot of doctors weighing in on the best treatment. The answers to some questions were clear, including the desirability of waiting for spontaneous resolution rather than doing urgent surgery. Thankfully, on Day Three her bowel opened up and she began to eat. (By the way, the only wonderful thing about NG tubes is that taking them out is one of life’s great pleasures; think ski boots and multiply by 100.) But whether she should go for elective surgery, given the near-certainty of future recurrence, and whether and how to modify her diet, were areas of great ambiguity.

On each of these, I liked the fact that the physicians laid out the plusses and minuses of the various actions. What was difficult – even for me – was how to deal with conflicting recommendations. Many folks emphasize the importance of a strict low-fiber diet, and yet one surgeon made clear that it probably doesn’t make any difference. (Mom chose to stick with the diet; mainly because doing something feels better than doing nothing). And we decided against elective laparotomy to “clean out the abdomen,” a big operation with no guarantee of success. This was the consensus judgment of several physicians, although there were a number of variations on the theme that could have led to some confusion.

All of this made me more convinced than ever of the need for a quarterback, one physician to synthesize all of the conflicting advice and present a unified recommendation to the patient and family. It’s what a good hospitalist does. In my mother’s case, this role was assumed by the lead surgeon, who also supplied me with some of the key literature, which was extremely helpful.

*  *  *

Mom, dad, & grandson Doug

Mom, dad, grandson Doug

Unlike Scott Simon’s mom, my mother’s hospitalization had a happy ending, at least for now. Overall, I was very pleased with the quality of care she received at UCSF Medical Center and would recommend it to other patients without the slightest hesitation. The nurses and doctors we met are bright, committed, friendly, and collaborative, and the systems we’ve put in place over the past decade – IT, handoff processes, whiteboards, and more – are making a difference.

That said, like all great organizations, every encounter provides an opportunity for improvement. I hope we can use my mom’s experiences – and those of other patients and families – to do a little better for the next patient.

45 Responses to “#MomInHospital”

  1. william reichert August 17, 2013 at 7:01 pm #

    Of all the complaints you mentioned bestI loved the one about the hospitalist acting as the “quarterback”. I guess you just don’t understand the power structure. A quarterback calls the plays. The hospitalist is really only the water carrier not the quarterback. The hospitalist is there to serve the real quarterback (in this case the surgeon who is really calling the plays.) The hospitalist is the attending of record but God help him if he acts like it and does something the surgeon dislikes even if the hospitalist is doing the right thing/
    I always love it when a family member wants me to tell them what all the various
    consultants think.AS if we all gather around the lounge every morning and discuss the case each day before going in to the room to see the patient. I asked our administration to
    provide typed progress notes so I had a slight chance of understanding the others doctors’
    thoughts on the case. No dice. I can read about 15% of what they write. Dont dare call them to ask what they think or many with react with anger for bothering them.

    It is amazing to me that you are unaware of the reality of the hospitalist’s situation,something that you yourself helped create.

    • a doc October 6, 2013 at 6:37 am #

      I agree, your complaint about hospitalist being quarterback does not make sense.

      You created the hospitalist role. The sad reality is they cannot string other specialities around. I have worked in the hospitals in varied settings academic and private and I can tell you in none of them would this fly.

      It is sad that you are so divorced from reality.

  2. Vikki Raven August 17, 2013 at 7:38 pm #

    Rob, this was fabulous . As a nurse I see all of this almost everyday ,it is our job to advocate for patients but there is much room for improvement. I’m glad Bernice is better and I hope she remains illness free. Again really great blog I intend to share with the folks I work with at my hospital .

  3. Miriam Kaufman August 18, 2013 at 3:11 pm #

    Great article!
    There is new(ish) technology to replace plastic NG tubes, it has been around for at least 30 years. It is the silicone NG tube. Still not a pleasant experience, but it is softer and more flexible. It can be left in for longer than a more rigid tube, but costs a lot more. Your hospital probably doesn’t think it is worth the extra money in someone who is likely to need it for 4-7 days!

    • Namerequired October 14, 2013 at 6:53 pm #

      I’d rather have the stomach fixed with an uncomfortable tube that doesn’t collapse when I apply suction to it, than something that’s only going to have to be removed and replaced with a tube that DOES work.

      There’s a reason we don’t use the damned things over the past 30 years.

      People HAVE to be uncomfortable at times. People HAVE to wait their turn at times.

      Ya’ wanna’ fix the system? Throw money at it. Pay for a one-to-one bedside physician and bedside nurse. Pay for a separate laboratory creatinine assay so you don’t have to wait for all of the other people in the hospital to have their labs done.

      It’s not an emergency CT unless there are signs of bleeding and hypotension. You didn’t bring her into the ER right away at first onset of symptoms, but blame the hospital for not being fast enough and high tech enough.

  4. Pam Mullins August 18, 2013 at 4:12 pm #

    I am a retired (1970-2008) UCSF RN and a UCSF pt 4 yrs ago. I have a few comments on your blog. I agree that things have progressed but one of the biggest slackers is effective communication between specialists,hospitalists,various hospital staff,patients/ family and receiving communication from referring or a patients non- UCSF doctors.Patient safety as well as cost effectiveness would be greatly enhanced if there were a central NATIONAL data base that a persons medical info could be accessed allowing someone from Fla to obtain care in CA or anywhere else.How many tests, labs or procedures are duplicated unecessarly because of lack of communication? Could we have a HIPPA compliant way of registering pts(? SSN) and doctors (DEA?) to access this data base? Intra-hospital communication between a patients caregivers and pt/family also can use some tweeking but getting the necessary systems in place ie: telecom,phone charting and ways to print info for pt /family all are cost dependent. Pro active investment could avoid many reactive expenditures.

  5. Joanne Turnbull August 18, 2013 at 5:59 pm #

    Thanks for this recounting. I’d like to chime in on IT and the ‘quarterback role,’ drawing from last winter’s experience at Mayo Clinic. I was there for a four-day diagnostic workup. The internal medicine doc was indeed the quarterback, deciding on the necessary specialists, receiving and synthesizing their input, and parlaying the treatment plan to the patient, me. Everyone was clear about their role. Each night, I was able to log-on to my account (yes, there’s a phone app) and read my clinic notes and lab results. Every clinical encounter included an assessment of the patient’s ability to understand. Everyone – from the volunteer in the cafeteria to lab personnel to the physician – conveyed the sense of working for the greater good and serving the patient.

    • Robert Ley, MD August 18, 2013 at 8:14 pm #

      Could you clarify? Was it an internist who was in charge, or a hospitalist? Since the system has moved to hospitalist inpatient care, having the patient’s primary care doctor ‘in charge’ of their hospitalized patients has become almost impossible. Perhaps a video link between the primary care doc and the patient would work. Then the vital information that the primary care doc usually has would not get left out of the treatment plan so easily, and the patient would have the reassurance of being able to discuss their questions and care with someone they already know and trust.

      • Pam Mullins August 18, 2013 at 9:00 pm #

        Again, communication is a major issue in health care.There really needs to be an effective way of getting info from PMD tp hospital staff (all levels), patients and families. This is particularly important in the elderly,emergency or non-english speaking patients.I really think communication should be a top priority and include all staff members. MD’s have their issues as well as nursing,pharmacy radiology etc.Maybe instead of hospitals spending quite so much money giving the lobby a facelift before JACHO it could be better invested in better defined communication systems.Video conferences, pt.access to same day records and perhaps a national data base is a start in the right direction.

        • Namerequired October 14, 2013 at 6:55 pm #

          REMEMBER: WE pay JACHO for their “accreditation.” You will NEVER fail. No hospital has except for one. And a fail doesn’t close the hospital.

  6. e-Patient Dave August 18, 2013 at 9:57 pm #

    First, thanks for another great essay. What I wouldn’t give to be able to write this much, so engagingly!

    Now to the task:

    > All of this made me more convinced than ever of the need for a quarterback,
    > one physician to synthesize all of the conflicting advice
    > and present a unified recommendation to the patient and family.
    > It’s what a good hospitalist does.

    Well, I wish there would be enforcement of this standard; it would require *knowing the case.* And during ALL my hospitalizations I was told in NO uncertain terms that no individual was responsible for coordinating my care.

    I’m gonna be a bit brusque here because I think it’s needed: from what I’ve heard, there’s a lot of kidding ourselves about how this is working out.

    As one example, the day after my nephrectomy the surgical floor had no idea that I had a massive met in my femur; they told me “time to stand up” and didn’t even know I was using a walker. (That’s not to mention that they forgot to remove my catheter that day, increasing the risk of infection. That wouldn’t be an MD’s job to monitor, anyway.)

    I was laboring under the delusion that my primary would make sure everyone knew my case, so I got mad at him. I soon learned that it’s explicitly NOT his job; the new role of “hospitalist” took over the case. Except in my 7 hospitalizations not once did anyone say “I’m taking responsibility for coordinating your case”; heck, I didn’t even have a consistent hospitalist across my stays. And the ones I did have were classic flip-through-the-chart “Now let’s see, who are you?” one-timers.

    So again, I wish there would be enforcement of this standard, with a family call bell to report “Hey – our coordinator has no idea what’s going on, and harm almost happened.”

    Sincerely – without this reality check, are we kidding ourselves? I’m all for any idea that works, and dead set against any shared delusion.

    Whatcha think?

    (They also lost my post-nephrectomy urine specimen (which drove my urologist up a wall) and even lost my kidney a year or two later – sent it somewhere for something and nobody knows where, so no cancer genome contribution for me. Those obviously aren’t the doc’s issue, but they add to my impatience with kidding ourselves about how great things are.)

    • william Reichert August 19, 2013 at 4:10 am #

      Dave,

      I am a hospitalist.Let me explain how things are.
      First of all, some preliminary housekeeping.
      It is most certainly the doctor’s job to decide when to remove the catheter. In fact, the nurse cannot remove it without a doctor’s order. Dont blame the nurse for this.

      Secondly, if you normally use a walker you should tell the nurse this in case she does not act like she knows. If you are allergic to corn don’t eat it even though it is on your tray. You must understand no one knows everything about you. Help them out. Yes maybe they should know. Dont expect them to know. Speak up. Use your common sense. Dont be passive.

      Now for the quarterback issue. The simple truth is this . If you want one person to be
      the quarterback then you need ONE DOCTOR ONLY. Once you get 2 or more there is going to be a different opinion from each because each doctor has different training and different experiences and attends different meetings and has a different idea of what the right way to treat you is. There is no “right way” 92% of the time so dont expect it. There are different ideas. The truth is there is not one doctor who can synthesize all the information and present a UNIFIED RECOMMENDATION, There
      are different ways to treat a patient and not a single right way.Consequently doctors
      do not agree with each other. If I think you need treatment x and the other guy thinks you need treatment y there is no way to do a little x and a little y. It is one or the other.
      This one captain of the ship idea is never going to happen unless you only
      have one doctor ( which I highly recommend).
      If the hospitalist is your main and only doctor ( this happens occasionally) then he knows what to do and can give you his recommendation. But if he is not your only doctor and he calls in other doctors then there will be differing opinions of what the best treatment will be.After all, if he calls in a second doctor he is admitting he does not really know what to do. Once the second ( or third or fourth,etc) doctor is called in they all have a different notions of what to do and these notions can change on a daily basis. So the hospitalist cannot synthesize the ideas of which he is not cognizant . Furthermore, at times the hospitalist will disagree profoundly on what the other doctor’s want to do. The consulting doctors have more power in the hospital pecking order so what they want goes. But if the hospitalist disagrees he is loathe to say he recommends what the other doctor wants to do. The doctor who is really making the decisions should be the one to explain the plan. And you should find out who that person is and insist on him explaining the situation.DO NOT rely on the hospitalist. After all , he has called in other doctors thereby admitting de facto he does not know what to do.
      I know this is unsatisfactory but it is the way it is. If your case is simple, you may
      get all the doctors agreeing If so, no matter who talks to you they will all say the same thing( although they may use different ways of saying things and confuse you).
      This cannot be helped. I honestly dont know what the answer is.But I do know this.
      Having more computers or white boards or patient advocates will not work because the doctors are too busy to use them.And they will NOT use them. SO dont hold your breathe waiting for this kind of thing to solve the problem

      In the old days your family doctor was the quarterback and you trusted his opinion. But nowadays the family doctors realize that going to the hospital means they see far fewer patients and means they have to take night call which is distasteful to them. SO we have hospitalists who take their place and of course have less of an emotional attachment to you since they dont know you. This system allows everyone to see more patients each year. SO the experience is not as good but more people get seen.
      Most people survive the experience but often feel uncared for or mildly abused in one way or another . I think Dr Wachter felt this way. And as a”VIP” it surprised and somewhat angered him. That is understandable but he is gong to have to get used to it. I was hospitalized last fall and for various reasons I felt somewhat abused myself
      although the overall outcome was really eventually quite acceptable.

      With Obamacare adding 30 million more patients to the insured population I believe you will see more changes as a result of the increased patient load and less patient
      satisfaction. I am sorry about that.

      In the meantime you need to become more proactive in your interchange with the medical profession. Ask more questions.
      Write down your concerns on a piece of paper so when you see the doctor ,
      push them for a coherent response to your concerns . Read about your condition.
      If you act engaged they MIGHT respond. YOU NEVER KNOW.

  7. Abhay Padgaonkar August 19, 2013 at 2:39 am #

    Great blog and thank you for sharing your personal story. And kudos to you for your honest reporting.

    Unfortunately, it raised more questions than answers and left me feeling even more petrified about hospitals.

    ED delays for “stat” orders, unnecessary x-rays, lack of primary doc assignment for 6 hours, no written traces, unpredictable rounding schedules, inexperienced and unsupervised interns, fabulous communicator surgeon clueless that he is speaking with a 77-year old, painful and annoying technologies, conflicting recommendations, and worse yet, nobody in charge.

    If this is presumably one of the better-run programs, doesn’t it make you wonder what goes on elsewhere?

    It is nice that you were “very pleased with the quality of care,” but somehow I find that conclusion contrary to your reported observations above. How would your mom answer the patient satisfaction survey?

    Whose job is it to find and overcome the chokepoints that would reduce costs substantially?

    Who is responsible for fixing this broken system?

  8. Bob Wachter August 19, 2013 at 5:23 am #

    To William and Dave — I’m not sure how this became a discussion about hospitalists; I was making the point that every inpatient really needs a quarterback. In my mom’s case, it was an excellent surgeon, and it worked pretty well. In a good hospitalist program, the hospitalist takes that role. In a bad hospitalist program, it doesn’t work very well. Ditto with a good and bad primary care-based hospital model. The reason I have supported the hospitalist model is that I am convinced that for the majority of patients, the probability of having a well trained, effective, and always-present hospital quarterback is higher under this model than any of the viable alternatives.

    It is important that whoever is taking the role of lead physician for a hospitalized patient introduce him or herself clearly to the patient and family, make his or her role (and that of the other clinicians) clear, and, if signing off to another physician, work as hard as possible to make it a seamless transition. That is what we try very hard to do in my hospitalist program, and I think we do well, although there is always room to improve.

    To Joanne — I too have been to Mayo and I think they do quite a good job of this. Of course, there are relatively few other places where people come for prolonged and semi-elective diagnostic workups.

    To Miriam — I too have heard that there are more comfortable NG catheters available. Since my blog, I’ve been told that my hospital is now looking into using them.

    To Abhay — my mom wrote a heartfelt thanks to the Chief Nursing Officer, so impressed was she with the quality of the nursing care she received. When she receives her hospital survey, I’m pretty sure she’d give it a top grade. As for me, I’d give it a B+. I’d say that the only egregious error, which was really one of inexperience and perhaps insensitivity, was the lung cancer discussion. She would not have known about the CXR/KUB if I hadn’t been there, and it doesn’t constitute an error — the decision to get the other x-rays was standard of care given the time it takes for a creatinine to come back.

    The rest of the issues represent standard clinical medicine even in today’s best hospitals (and I’ve visited all of the “top hospitals” in the US). But that shouldn’t cause us to rest. It is clear to me that there is room to improve as we begin to think more deeply about our processes, our technology, and — most importantly — how care is experienced through the eyes of the patient. The last question you pose (who is responsible for fixing a broken system) is the most profound and challenging of all. We have too many silos, and your question reminds us that not only do we need to integrate clinical care better, we also need to integrate our problem solving work.

    Thanks to all for your interesting and thoughtful comments.

    • Carolyn Canfield August 19, 2013 at 3:32 pm #

      Accounts from healthcare professionals as patients and patient families always interest me, and yours, Bob, is well-told. Your keen safety awareness and focus on improvement serve us well. Thank you.

      Now for a few questions from the patient perspective. Would (or did) UCSF pick up the “only egregious error” in its patient harm detection system? If not, what is missing in the error reporting and response system?

      Was a remedy provided by way of apology to your mother and your family? Did reduction or elimination of “inexperience and perhaps insensitivity” get addressed as a result of this incident? Was this error treated as an incident subject to review? Does anyone else in the system see it as “egregious”?

      How would (will) you suggest a system improvement to ensure that errors with such a potent impact on patients and families get reported for every patient every time? Otherwise, how can we assure remedies in the particular case and no recurrence to protect others from harm?

    • Abhay Padgaonkar August 19, 2013 at 5:38 pm #

      To Bob – Thank you for your thoughtful and timely response. (You had already said that your mom is too polite.)

      However, if this is the “standard clinical medicine” even in top hospitals then it is time to acknowledge that we have set the bar too low. We need to challenge the standard and stop pretending that anything that doesn’t kill the patients makes them stronger!

      Speaking as a management consultant who has led hospitalists, I believe that any negative impact to the health, experience, or the wallet of the patient must be seen as an error.

      I also believe that it is primarily the job of the hospital administrators, as leaders of the organization, to fix the broken system. Unfortunately, there is scant evidence of their problem-solving skills (American Medical News – http://www.amednews.com/article/20130715/business/130719990/1/?utm_source=nwltr&utm_medium=heds-htm&utm_campaign=20130715), but plenty of evidence of them putting profits before patients.

  9. e-Patient Dave August 19, 2013 at 8:23 am #

    First, congratulations again on your wonderful outcome! The more I read about cases like this, the more prepared I am to have the same. :)

    > I’m not sure how this became a discussion about hospitalists

    You know I’m not a flamer guy, but for me (and I imagine many other patients) your last sentence accidentally touched a nerve. Let’s look at my specifics.

    > It is important that whoever is taking the role of lead physician
    > for a hospitalized patient introduce him or herself clearly to the patient and family,
    > make his or her role (and that of the other clinicians) clear, and,
    > if signing off to another physician, work as hard as possible
    > to make it a seamless transition.

    Agreed. During my seven hospitalizations for me near-fatal illness I expected that would naturally be the case.

    During my four weeks of interleukin treatments, in a semi-ICU, it worked: the physician was a nurse practitioner intimately familiar with my whole case, on top of it across hospitalizations.

    Not so during my nephrectomy and my two hospitalizations for pathological fractures. After the nephrectomy the surgeon was the “lead physician” – a GREAT guy, skilled and gentle. But he clearly didn’t see himself as responsible for making sure the nurses understood my whole case and knew what to do.

    After my two femur repairs I imagine the orthopedic surgeon was the lead physician, but she was never around. I couldn’t even get an answer to any question in less than a few hours.

    Maybe I’m remembering this wrong six years later, but however it *should* have happened, I just remember hours and hours of lying there waiting. And I particularly remember being told explicitly that *nobody* was responsible for coordinating things. Boy was that a letdown when I was there to avoid dying. :-)

    As I say, you know me well enough to know that I’m not a nasty flamer. But this is a gaping hole in the experience a lot of us have, and yeah, it touched a nerve. I suppose I should go read up on the formal definition of responsibilities between hospitalist and rest of team!

    And again, most importantly I’m glad your mom’s case turned out great.

    And during my IL-2 treatment my NP was superb!

    • Debi Wong, FNP August 26, 2013 at 11:05 pm #

      It has been interesting to see your dialog with William and Bob. I am a hospitalist NP and when doing night cross coverage at my prior hospital, I was told by more that one patient or family member that my explanations were very helpful to them. Unfortunately when someone was admitted during the late afternoon, the results of the workups do not usually become available until after the day hospitalist goes home, so it was left to the night team to inform the patient and/or their family of the results of the tests.

      I am now working days, and hope my explanations can be of just as much value.

      BTW, most hospitalists work a block schedule, so you will see one for as long as a week, who alternates with another provider when their week is up. Unfortunately patients get admitted all times of the week, so it is possible to see a change over right after you have been admitted. Most services try to maintain continuity, so that if you are unfortunate to have to stay greater than a week, you will get assigned the same original provider again. Hope that helps and good luck to you.

      • e-Patient Dave August 26, 2013 at 11:58 pm #

        Thanks for your note, Debi!

        What I as a patient was concerned about was whether people really understood what my case was about from day to day, so we didn’t have to start over from scratch (or worry about dropped balls). In your experience what should families be aware of, re the reality of coordination of care? Are we right to expect it as normal, and/or do we need to be aware that there’s a high risk of weak coordination?

        • Debi Wong, FNP August 27, 2013 at 5:21 am #

          Dave:

          Yes, families do need to be aware of the vulnerability of what those in the field called the “hand-off”. This risk exists whether professional hospitalists like Bob or intern/residents are caring for you in the hospital. What this field is trying to do is minimize that risk whether it be through written, spoken or some sort of electronic form of communication.

          This also happens between the hospitalists and consultants. For example, the other day, a surgeon who was consulting on one of our admissions went ahead and discharged the patient. So they will need to prepare the discharge summary which should but will probably not include a medication reconciliation process. We can only hope that the patient whose medications were held prior to surgery knew to restart their medications.

          Statistically, the highest risk of a “miss” or an adverse outcome is during a transfer of a patient.

  10. Larissa Lee August 19, 2013 at 12:46 pm #

    This was a wonderful blog. Thank you for sharing your “at-bedside” moment. As healthcare professionals we all have our stories of our personal experiences and left with the need/the want to make things better — from treatment plans, communication, jargon-talk and (believe it or not) handwashing!

  11. Pat Mastors August 20, 2013 at 3:22 pm #

    Great discussion, thank you, Bob. So glad your mom is recovering well. My observation:

    “… if you normally use a walker you should tell the nurse this in case she does not act like she knows. If you are allergic to corn don’t eat it even though it is on your tray. You must understand no one knows everything about you. Help them out. Yes maybe they should know. Don’t expect them to know. Speak up. Use your common sense. Don’t be passive.”

    Thank you, William Reichert, for this honest and critical advice. Having advocated for several family members through hospital stays for life-threatening conditions, this is the mindset we need to encourage. Not to shame or call out anyone, but (at least until the dysfunction Bob Wachter describes gets MUCH improved), to act as that second set of eyes and ears. Again, validating that patents/families are the most under-utilized resource in health care. If only they knew it, they’d know to act on it. It begins with simply acknowledging how fractured and imperfect hospital care is–even in the best facilities.

    • william Reichert August 20, 2013 at 4:21 pm #

      Thanks for that ,Pat Masters. Last year I had prostate surgery and during the first night
      my wife, who is an ICU nurse, noted that no more urine was coming out of my catheter for 2 hours. We called in the nurse who said more or less, “dont worry , it happens all the time on this floor.” I thought, well maybe so, but if you dont mind please hang up a liter of fluids and let’s get my kidneys working ( the catheter was NOT blocked ). It took a lot if insisting to get them even to call the doctor to ask him about “no urine for 2 ours” which was apparently the standard on that floor at the time. Eventually, the fluid was approved and arrived.My kidneys responded . I understand that nurses are loathe to call the doctors at night. SOmetimes they get mad. And I know it should not be that way.
      BUT IT IS, So you have to insist if you think it is important. I thought what is the big deal about some IV fluid?. I have good heart. I will not develop heart failure with one liter of fluids. SO you have to insist. Now I know IT SHOULD NOT BE LIKE THIS. But
      it is and furthermore, it has been this way at least since 1970 when I first went in to medicine (I am a retired physician ). And here is my main point. If you have a problem
      that has existed for over 40 years you can be pretty sure this is NOT going to be easy to fix. Because Dr Wachter is NOT the first person to perceive issues that need
      addressing in hospitals. And may I suggest that these problems may NOT BE FIXABLE. The reasons for that are complex and that fact is not one that most people
      want to even investigate. So you need to NOT assume that everyone is doing the right thing now or in the near future.
      And not be passive especially if you think the issue is worth making a fuss. Which sometimes it is.

      • Pat Mastors August 20, 2013 at 6:29 pm #

        The only thing that will make these problems go away is more free-market forces. That means more engaged and aware patients/consumers driving their health care choices and decisions, something I spend a lot of my time on. Meantime I worry about those hapless patients and families who have less awareness than anyone who found their way to this forum – that includes the vast masses. The new wave of insured is not going to make improvement any easier.

        Working in patient advocacy since losing my father, I consider myself as well-informed as any non-medically trained person…but it took everything I had to stay on top of my daughter’s care this spring when she was hospitalized with a rare nerve disorder. (I blogged about it at http://www.kevinmd.com/blog/2013/08/gratitude-terrified-parent-kindness-shown.html) I had no illusions things would go smoothly without me there…not due to anyone’s deliberate act…just the fractured nature of how things get done. With everyone responsible, no one is responsible. Like you, I was just so grateful to get my daughter out of there and home again.

        Maybe I’m a dreamer, but I believe we need to collectively push for every click in the dial of improving patient safety. That means promoting a culture where it’s OK to speak up, and where doing so will earn respect rather than resentment. I do see it’s much better now– even if only anecdotally–than it was even 5 years ago. We need to call out the heroes and the non-performers, which blog posts like this one do quite well!

        • william reichert August 20, 2013 at 8:33 pm #

          I read your account of your experience with your daughter with GBS.
          It reminded me of an experience I had about four years ago. I was attending on a diabetic patient and trying to adjust her insulin dose. I could not get the nurses to document the insulin dose she got and record the blood sugar values so I could see what effect the insulin was having. The charting was not set up to correlate the two values to clearly indicate which dose went with which blood sugar. A woman was in the room and she appeared both interested and intelligent. So I asked her SHE would be willing to assist with the this documentation so I could get the dose right. She said yes. So I explained what was needed. And she did what I asked. Now the task became doable. We got the dose adjusted and she went home on the right dose. The problem is, as you pointed out in your last post that it is unusual for a family member to be interested,capable and willing to help out like this at least where I was working.

  12. LindenGrove August 22, 2013 at 3:30 pm #

    Glad to hear she had a happier ending!

  13. menoalittle August 24, 2013 at 2:05 am #

    Bob,

    Keep in mind that if the heath care professionals caring for your mom knew who you are, they had to be trying to expedite.

    Thus, it seems to me that the delays in the ED were due to workflow disruption and communication impediments caused by the EHR and CPOE systems just deployed. Nurses complain about these unintended consequences often as witnessed by discourse at Sutter, in your neck of the woods.

    The stuff that the famous and revered non flame e-patient Dave describes is almost assuredly and paradoxically due to the adverse impact that the electronic automation of care has on care, causing health care professionals to care more about the machine than the patients.

    Best regards,

    Menoalittle

    • william reichert August 24, 2013 at 12:52 pm #

      To Menoalittle,

      It remains to be seen whether computers will enhance or detract from the core business of hearth care after all is said and done. AS of now it is a mixed picture. Computerizing prescriptions at discharge
      is in my opinion a real step forward especially eliminating bad handwriting and allowing
      other members of the health care team to see what others are ordering at discharge.
      The possibility of eliminating handwritten notes would be a big step in bringing the
      medical record from the nineteenth to the twenty first century and allowing all members of the health care team to see what others are thinking especially nurses who spend unnecessary time trying to translate written orders into understandable requests/. With this information maybe the “quarterback ” on the team could tell the patients what others are thinking and planning.Maybe.
      Unfortunately there seems to be an insatiable hunger for controllers to request
      data entry into the computers and the increasing number of demands eventually place a stress on the computers
      capacity so that the computers slow down to the point of being a real impediment to the
      real core work that health care workers must complete.At my work place I often have to
      get 2 computers working at once to avoid this log jam in my work. Administrators do not seem to have the funds available to keep the systems working properly . No one seems to be willing to recognize that adding more and more demands to the computer data entry
      eventually will bring the whole system down.And , consequently, it is a frustration borne silently by the staff.

    • e-Patient Dave August 26, 2013 at 11:59 am #

      > The stuff that the famous and revered non flame e-patient Dave describes
      > is almost assuredly and paradoxically due to the adverse impact
      > that the electronic automation of care has on care

      Hi Menoalittle – I don’t know you so I can’t read your mind, but I have to say I burst out laughing (a literal LOL) at this. May I ask what you know about the status of automation at the place where I was?

      Do I hear you correctly? I think you suggested that (for instance) the surgical floor would have been more likely to know about my bone met, and they would have been more likely to remove my catheter, if they weren’t using an EHR?

  14. Tim Tweeter August 24, 2013 at 1:00 pm #

    Why was the July intern harried? Did any one ask the intern how much time he/she spent taking care of the, what I hear is, a user unfriendly time consuming care demanding EHR, CPOE, and CDS system?

    As for the ED delays, does UCSF use Picis ED Pulsecheck? Its system was just put on recall as reported on the FDA website.

    I just wanted to let you know.

  15. Karen Roberts, NP August 26, 2013 at 3:20 pm #

    Interesting article. The experience of hospitalization is always an interesting one, and if often comes down to unspoken rules. For example, my father waited for 8 days with a broken femur prior to surgery because all the capable surgeons in a tri-state area were away at a conference (this was spring break, and it was a complex post replacement fracture). Although the surgeons were an hour’s flight away, no one offered to call and see if one would come back to perform surgery. Instead, an 87 year old man was kept on bedrest for an extended period of time prior to a 6 hour high risk surgery. This was related to the unstated rule that “we don’t bother the doctors.”
    The hospitalists had wildly differing ideas and ways of handling his case, and when you are dealing with a multiweek stay, you encounter multiple hospitalists. Fortunately, his nursing care was quite good for the most part.
    In terms of technology, one thing I assumed EHRs were to solve was the inputting of demographic info. My father (and I, in previous hospitalizations) endured the following: an hour of “admission questions” in the ER, while in pain, another hour of the same “admission questions” on the unit, while he was under the influence of painkillers, and in my own case, another hour of “admission questions” in surgery while anxiously awaiting a procedure. These all took place in the same hospital, within the same 8 hour period. To me, it says that the hospital doesn’t trust its EHR. If it did, the staff member would see that the information was just updated one hour ago, ask if anything had changed, and move on. This is an insane waste of expensive nursing time.
    There are so many wasteful processes in place, but it takes time and will to study and alter them, and the resistance from those who say “but we’ve always done it this way” is extreme.
    I have found hospital care to be one of the most frustrating experiences of my life, both as a patient and a caregiver.

  16. Bob Wachter August 27, 2013 at 4:33 am #

    It’s getting better – this is an area in which both IT and some of the policy changes have helped. IT, since it is much easier for all the clinicians to read each other’s notes, and because good IT embeds a signout system that helps by creating a structured place for a brief synopsis and a bunch of “if/then” statements. The main policy change that has made a difference is the readmission penalties, which has forced hospitals to think about the discharge process in a much more intentional way than they ever did before.

    But the risk of handoffs partly depends on the commitment of the individual docs and their program to make this right. In my program at UCSF, we take this very seriously. For example, when I took over my colleague’s service to cover this weekend, he spend about 20 minutes on the phone with me on Friday night, telling me about each of the patients (both of us following along on the EMR), and when I handed the service back to him last night, I spent about the same amount of time going through what had changed in his patients and describing the 3-4 new patients the team received over the weekend. This degree of attention to sign outs is, unfortunately, unusual.

    • Debi Wong, FNP August 27, 2013 at 5:27 am #

      Hello Bob!

      We as a small team of 3 docs and one NP/PA go through a process in the morning receiving sign offs from who ever is outgoing, plus whoever spent the previous nights on admissions. In the evening, we notify the oncoming night doc of any patients we feel will have issues for cross coverage, then the process repeats itself daily.

      Am looking forward to meeting you at the UCSF course in October/November!

    • william reichert August 27, 2013 at 12:37 pm #

      Bob,

      I take it that your EMR. has all. the progress notes types and. legible as you say they are easier
      to read. Wonderful. I asked our administration to do this and I would allow them to deduct the cost from my pay . They refused. Good for you and your hospitlal. Welcome to the 21st century.

      I have to say however that the sign out. process you describe is in my experience a
      frustrating ordeal.
      In20. minutes your collegue tells you all about his 20 patients. With many if/then”
      considerations. Let us say the patient has 12 on going things on his problem list.
      Well. 12 times 20. is 240 the last time I checked. So you. are expected to listen
      to 240 different areas of concern and retain them by the following day. This
      is impossible. Something that MIGHT. work. is a dictated summmary which
      you could listen to the next day right before. you. saw the patient.
      But since you can read faster than you can speak, the best thing,
      would be an accurate and readable problem list in the chart for ALL
      to see. Typed of. course.
      Because the process you describe is inadequate, the patient
      will experience what was described in the submissions to this blog
      above, namely, a new doc on the case who has to get to know
      the patient anew.

    • Antonia Rossi August 28, 2013 at 4:33 pm #

      Unfortunately many hospitalizations become problematic or critical, because of the lack of attention to detail, as you explained when you hand off , you spent 20 plus minutes explaining each patients’ status to the next physician- Most hospital care basically takes the initial Potential diagnosis and runs with it- rather than looking at the patient anew and truly examining the patient to figure out what is correct diagnosis- Too many hospital it’s , doctors are using cut and paste in their reports thereby using prior records information in their new report. My father had a high fever and abdominal pain- the ED dept did a check X-ray abdominal CT- he had no clinical issues with breathing, O2 sat, ect.. But ER doc wrote possible pneumonia (based on old check X-ray from 7 months prior) which he cut and pasted findings to put into his report. My father has CHF, yet te hospitality ran with the possible pneumonia diagnosis, and gave him IV fluids for three days, resulting in him gaining 14 pounds over those days, he became critically ill with respiratory failure, and the culprit from the beginning was his bowel had become lodged in his scrotum, but this was never known early on since they did not do a KUB, until he was critically ill. He underwent emergency surgery hartmanns procedure, to remove the infected part of colon, and now has a colostomy bag. He spent three months in hospital to recover, he became critically because of his care, which exacerbated his CHF, did not address his abdominal pain earlier in hospitalization to determine further the cause, ie…KUB, instead assumed pneumonia and gave him fluids liberally even though he is in his nineties and has CHF. Unfortunately this is not uncommon, everybody dropped the ball, and the only reason he survived is because his family started to micromanage his care- many people in medicine particularly hospital care just do not pay attention to detail, and examining patients, they just continue whatever prior report states, rather than really diagnosing, caring for patient- he gained 14 pounds in four days, and nobody noticed- he should have been monitored closely daily for any weight gaine, and fluids should been given very carefully. BTW this happened at hospital affiliated with well known Boston hospital.

      We have to realize that often times great care and attention to detail is lacking in hospital care, and often times this is why medical care costs so much, because so much money, effort, etc…. Have to be expended to recover from many of these early missteps with elderly and fragile patients.

      • william reichert August 28, 2013 at 7:28 pm #

        Antonia Rossi:
        Yes, you are correct. TAKING THE BALL AND RUNNING WITH IT may result in running in the wrong direction. And yet……. and yet…… when the hospitalist comes in to the room and starts asking the same questions that have previously asked, some folks, some family members become angry that these questions are being re asked. Some of the concerns in the posts on this blog make this point. “Can’t they just read the EMR?” they declare. They may see the questions as bothersome and evidence that the physician has not read the medical record when in fact he/she is really trying to make sure that the diagnosis and treatment plan are appropriate. I would say that when I see patient for the first time I NEVER assume the previous physician’s diagnosis and plan is correct until I go over the whole story AGAIN.
        About 10% of the time I discover something has been overlooked and a change in the plan
        is indicated. This may offend some people while simultaneously improving their chances of a good outcome.

        • Antonia Rossi August 28, 2013 at 9:27 pm #

          William Reichert:

          Happy to hear that you practice medicine by going over entire story when seeing patient for the first time- and you don’t assume previous diagnosis is correct-but truly start anew. However, my experience is that this is not very common, many time if hospitalist asks many questions, they are just asking but still pursuing the “wrong diagnosis”- no one seems to want to or be able to truly “practice” medicine by examining patient, listening, reviewing medical history, following up with PCP, as I stated previously my father was given fluids liberally- even though he has CHF, was rapidly gaining weight, – everybody nurses included just followed orders based on an erroneous diagnosis, a careless hospitalist, etc..- YOU are unique because you are asking questions, and truly using the answers to perhaps change course, and explore other possible causes – my experience has been that everyone jumps on board with the first suspected diagnosis-and runs often in the wrong direction- until things get very bad very fast- and what should have been clear three days ago, is now clear- but the patient is now very sick, the family is distraught, and patient is in ICU with a long recovery ahead. I applaud your way of practicing medicine- asking questions and not letting suspected diagnosis cloud or influence you care of patient- but rather start anew so that patient truly gets examined.

  17. Christine Morton August 27, 2013 at 8:15 pm #

    Thank you for sharing this personal story – your assessment of your work place and colleagues and their care of your mother (who I assume granted you permission to share these details?).

    I have two comments/questions.

    “…while the nurses and patient care assistants (PCAs) were excellent at introducing themselves and writing their names on the whiteboard, the doctors were not. Some didn’t introduce themselves at all; most did, but their roles were unclear. There were no face cards, and no physician names on the whiteboard.”

    1. Why is the solution for the problem of MDs not introducing themselves when they come into a default technological one? This assumes doctors can’t and won’t ever be bothered to adhere to important social norms of interaction — I wonder what else will they feel doesn’t apply to them if this simple behavioral norm can be so easily replaced by a techno-fix.

    RE: one team member to be our official jargon-detector
    2. Patient-centered care and advocacy have existed for 50+ years in the area of childbirth. Unfortunately what has happened has been the slow marginalization of childbirth educators in providing independent, evidence-based information about effective care; and in the past 30 years, the introduction of a new patient-advocate role, the labor support doula. Although in the majority of cases, the “patient” is a healthy woman undergoing a normal physiological experience, the “jargon-dectector” is still critical, with significant numbers of women undergoing induction for non medical reasons (with little awareness of why or what is involved) and unacceptably high rates of cesarean performed during labor for non-emergent indications. Yet doulas, and other patient advocates in this space, are too often dismissed by providers because of divergent beliefs about the nature of pregnancy and/or the role of medical interventions. I’m sure some of this plays out in other areas of medicine (probably most relevant in end of life care). I’d love to see a discussion of patient-centered care that addresses these philosophical differences.

  18. Mt Doc August 28, 2013 at 1:48 pm #

    A few points from a practicing hospitalist and former PCP internist.

    I agree with Ms Morton that there is not a technological fix to doctors not introducing themselves. UCSF is a teaching institution which is where the doctors in training learn how to behave from their mentors and teachers such as yourself. It is fortunate that only a minority of doctors in your mother’s care ignored this social nicety but the staff and faculty there are the ones who set the culture. They are also the ones who should address the behavior of the harried intern who delivered a diagnosis of cancer without apprently knowing your mother’s history, to prevent a repeat of this problem.

    It is almost impossible for most hospitalists to predict when in the day they will see a given patient. When I arrive on my shift I see the sickest or unstable patients first, followed by any new admission from last night, followed by patients who are ready for discharge, followed by stable patients. This sequence is interrupted by admissions or patients experiencing acute problems throughout the day and may change if a family member arrives who needs a discussion for care planning purposes. It changes on a daily and even minute-to-minute basis. I really wish there was a more predictable schedule I could follow but this is the reality.

    There is indeed a pecking order of sorts in the hospital. If I ask a subspecialist to see a patient and then do not follow that advice I would have to have a very good reason for doing so. The subspecialist has more training in his field and carries more weight, especially medicolegally.

    There will be flaws in any system you have. The advantage of work load restrictions and the current method of having hospitalists care for inpatients rather than the primary doc is that the physician is better rested and there is always coverage available. The flip side is that the patients are not as well known to the doctors. I can assert that if I personally do not do the H&P, my knowlege of the patient is not as good no matter how much time I spend reading notes. I think most doctors process information the same way, which leads to us asking the patient to repeat the history. It may be tiring for the patient but it helps the doctor to hear the story first hand.

    Cross coverage is also difficult under this system. Covering 20 patients each of whom is on a dozen or more meds and each of whom has half a dozen or more problems requires some dependence on the medical record. I think realistically sign-offs focus on anticipated problems. There is only so much data the human brain can wrap itself around at one time. Electronic records solve the legibility problem. Unfortunately most medical record systems are built to enhance coding, monitoring for “quality assurance” (usually a euphemism for cost containment) and billing purposes. Notes currently reflect this – in order to get paid you have to document a lot of extraneous data that detracts from the narrative value of the chart. This REALLY needs to change. It’s probably going to get worse. I’m told by a friend who works for the Blues that there are currently over 16,000 billing codes and I hear this is going to expand to more than 60,000 for “greater accuracy”.

    I agree communication is a major problem to be overcome with the current setup, particularly between the hospitalist and the primary care MD who will carry the ball after the patient is discharged. The old system of the PCP managing the patient in the hospital was better in some of these regards but had its own problems.

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