Devin J. Horton, MD

I’m actually not a football fan, I didn’t even know who Ray Rice was until I saw on CNN the now-infamous elevator video of him punching his then-fiancee an elevator and then dragging her unconscious body through the door. But after only 10 minutes of watching the different experts weigh in, including the ex-wife of Mike Tyson/domestic-violence–survivor Robin Givens, I realized my shoulder muscles had started to tense. I was getting the same knot in my stomach I get when faced with an impossible social problem in the hospital that I can’t fix: the alcoholic in awful withdrawal who refuses to go to treatment; the homeless man with heart failure who won’t follow-up at his appointments; the unfunded dialysis-dependent immigrant who gets dialysis only once a week, emergently, in the ED; the very elderly women with a fractured hip who insists on going home. And, of course, suspected elder-abuse or domestic-abuse victims, who are discharged back to the house they had come from.

©Makitalo/thinkstockphotos.com

Rice’s wife, the former Janay Palmer, issued a statement essentially saying everyone needed to mind their own business and that she would support her husband.

She is, of course, correct; it is their business. But as is so often the case when something tragic happens to or regarding a celebrity (whether it is Robin Williams’s suicide or Philip Seymour Hoffman’s drug abuse) their life in the spotlight then becomes a mirror to society’s woes and a platform, for better or worse, to discuss issues that affect the masses.

As I watched the news, the frustrated part of me, the controlling-fixer part, wanted a more logical and just (in my mind) outcome: a declaration that she is leaving the relationship, his suspension causing him to enter a life of counseling and successful reform. But the realistic part of me – the part that saw my mom stay with my dad despite years of pathologic alcoholism and then, once she had kicked him out, go directly to another women who then supported not only his drinking but also his unemployment for 13 years until the day he died from the disease – knows relationships are complicated and often pathologic.

I also know from both my own experience and my experience as a physician, that until the victim, whether it is the drug addict, the alcoholic, or the elder abuse and domestic abuse victim, decide for themselves that they want to change, those of us who want to help are relatively helpless.

In most of my patients with drug and alcohol addiction, and in my handful of suspected abuse cases, the outcome is almost always the same disappointing but almost scripted scenario. Addiction or abuse is suspected by one of the providers, house staff, nurse, medical students, or me because of the clinical situation, something overheard by a nurse, or the concerns of a family member. We try to gain more insight or information by talking to the family or patient.

We consult social work and the note inevitably says "patient denied problem/refused treatment at this time. Resources and contact information were provided to patient and family."

When I read those words, I get the same muscle tension and helpless knot in my stomach as when I was watching the news. My body aches as my mind makes the painful realization and transition from, "There must be something we can do" to "There is nothing more we can do."

We discharge the patient, "resources" in hand, and simply hope.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July 2013, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

I’m actually not a football fan, I didn’t even know who Ray Rice was until I saw on CNN the now-infamous elevator video of him punching his then-fiancee an elevator and then dragging her unconscious body through the door. But after only 10 minutes of watching the different experts weigh in, including the ex-wife of Mike Tyson/domestic-violence–survivor Robin Givens, I realized my shoulder muscles had started to tense. I was getting the same knot in my stomach I get when faced with an impossible social problem in the hospital that I can’t fix: the alcoholic in awful withdrawal who refuses to go to treatment; the homeless man with heart failure who won’t follow-up at his appointments; the unfunded dialysis-dependent immigrant who gets dialysis only once a week, emergently, in the ED; the very elderly women with a fractured hip who insists on going home. And, of course, suspected elder-abuse or domestic-abuse victims, who are discharged back to the house they had come from.

©Makitalo/thinkstockphotos.com

Rice’s wife, the former Janay Palmer, issued a statement essentially saying everyone needed to mind their own business and that she would support her husband.

She is, of course, correct; it is their business. But as is so often the case when something tragic happens to or regarding a celebrity (whether it is Robin Williams’s suicide or Philip Seymour Hoffman’s drug abuse) their life in the spotlight then becomes a mirror to society’s woes and a platform, for better or worse, to discuss issues that affect the masses.

As I watched the news, the frustrated part of me, the controlling-fixer part, wanted a more logical and just (in my mind) outcome: a declaration that she is leaving the relationship, his suspension causing him to enter a life of counseling and successful reform. But the realistic part of me – the part that saw my mom stay with my dad despite years of pathologic alcoholism and then, once she had kicked him out, go directly to another women who then supported not only his drinking but also his unemployment for 13 years until the day he died from the disease – knows relationships are complicated and often pathologic.

I also know from both my own experience and my experience as a physician, that until the victim, whether it is the drug addict, the alcoholic, or the elder abuse and domestic abuse victim, decide for themselves that they want to change, those of us who want to help are relatively helpless.

In most of my patients with drug and alcohol addiction, and in my handful of suspected abuse cases, the outcome is almost always the same disappointing but almost scripted scenario. Addiction or abuse is suspected by one of the providers, house staff, nurse, medical students, or me because of the clinical situation, something overheard by a nurse, or the concerns of a family member. We try to gain more insight or information by talking to the family or patient.

We consult social work and the note inevitably says "patient denied problem/refused treatment at this time. Resources and contact information were provided to patient and family."

When I read those words, I get the same muscle tension and helpless knot in my stomach as when I was watching the news. My body aches as my mind makes the painful realization and transition from, "There must be something we can do" to "There is nothing more we can do."

We discharge the patient, "resources" in hand, and simply hope.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July 2013, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

I’m actually not a football fan, I didn’t even know who Ray Rice was until I saw on CNN the now-infamous elevator video of him punching his then-fiancee an elevator and then dragging her unconscious body through the door. But after only 10 minutes of watching the different experts weigh in, including the ex-wife of Mike Tyson/domestic-violence–survivor Robin Givens, I realized my shoulder muscles had started to tense. I was getting the same knot in my stomach I get when faced with an impossible social problem in the hospital that I can’t fix: the alcoholic in awful withdrawal who refuses to go to treatment; the homeless man with heart failure who won’t follow-up at his appointments; the unfunded dialysis-dependent immigrant who gets dialysis only once a week, emergently, in the ED; the very elderly women with a fractured hip who insists on going home. And, of course, suspected elder-abuse or domestic-abuse victims, who are discharged back to the house they had come from.

©Makitalo/thinkstockphotos.com

Rice’s wife, the former Janay Palmer, issued a statement essentially saying everyone needed to mind their own business and that she would support her husband.

She is, of course, correct; it is their business. But as is so often the case when something tragic happens to or regarding a celebrity (whether it is Robin Williams’s suicide or Philip Seymour Hoffman’s drug abuse) their life in the spotlight then becomes a mirror to society’s woes and a platform, for better or worse, to discuss issues that affect the masses.

As I watched the news, the frustrated part of me, the controlling-fixer part, wanted a more logical and just (in my mind) outcome: a declaration that she is leaving the relationship, his suspension causing him to enter a life of counseling and successful reform. But the realistic part of me – the part that saw my mom stay with my dad despite years of pathologic alcoholism and then, once she had kicked him out, go directly to another women who then supported not only his drinking but also his unemployment for 13 years until the day he died from the disease – knows relationships are complicated and often pathologic.

I also know from both my own experience and my experience as a physician, that until the victim, whether it is the drug addict, the alcoholic, or the elder abuse and domestic abuse victim, decide for themselves that they want to change, those of us who want to help are relatively helpless.

In most of my patients with drug and alcohol addiction, and in my handful of suspected abuse cases, the outcome is almost always the same disappointing but almost scripted scenario. Addiction or abuse is suspected by one of the providers, house staff, nurse, medical students, or me because of the clinical situation, something overheard by a nurse, or the concerns of a family member. We try to gain more insight or information by talking to the family or patient.

We consult social work and the note inevitably says "patient denied problem/refused treatment at this time. Resources and contact information were provided to patient and family."

When I read those words, I get the same muscle tension and helpless knot in my stomach as when I was watching the news. My body aches as my mind makes the painful realization and transition from, "There must be something we can do" to "There is nothing more we can do."

We discharge the patient, "resources" in hand, and simply hope.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July 2013, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

I went to the American College of Physicians meeting in Orlando this year and attended a meeting about balancing life and work. Seems a little early in my career for such self-help I know, but I’ve always been a little too self-aware.

The speaker was Linda Clever, an internist and professor at the University of California, San Francisco, who is also a dynamic woman who has written books on living life with a busy career. The 1-hour group discussion was a nice change of pace in a conference full of experts talking about guidelines. I sat down next to an older couple as I settled in for the hour, delighted there was not a PowerPoint in sight. We were quickly asked to break into small groups to talk about strategies for avoiding burnout; my group ended up being me, and the couple.

©redkoala/fotolia.com

They must have been in their 70s, maybe even 80s, both retired. He had been a neurologist for more than 40 years (in his day neurology was part of internal medicine, thus his presence at ACP), and she had been a journalist. It seemed fitting that here I was, in my first year as an attending, looking forward into a career and unclear exactly where it was headed, filled with uncertainty; and there they were, an entire career and life behind them, comfortable and confident for the ride they had had. We got started.

I asked them what they had done to try and maintain balance, to have a life amongst a career, or rather a career amongst a life. The wife, short and plump with round thin-rimmed glasses tucked into white hair, could have been plucked right out of a story about the North Pole. She began to recount some of the lessons they had learned. She talked lovingly of her husband and how he was always so engaged and interested in everything and that he was always volunteering to be on this committee or that committee. He sat smiling with big, bushy, white eyebrows, clean-shaven face with a yellow short-sleeve dress shirt and a red and blue tie that hung 2 or 3 inches above his belt. Short like his wife, his legs seemed to swing back and forth under the chair like a child at a playground.

"It always was interesting!" he exclaimed, waving his hands in excitement. "To me it never felt like work. Even in medical school I wanted to be involved in anything."

I thought back to my own days of medical school, involved in or leading multiple activist groups, often to the detriment of grades, and now my already growing list of committees and "nonclinical" activities.

"Once we had children," the wife went on, "I would tell his secretary to schedule school performances and sporting events, right there in his appointment book. If we did that, he never missed an event. In fact, the kids never even knew how busy he was because he was always there. It wasn’t until they grew up that they understood how much he was juggling." His smile just pulsed into an even bigger smile, chuckling here and there as she talked. "So that would be my recommendation to you. Be deliberate about your time with your family; schedule it like you would anything else. "

I made a mental note, arguing briefly with myself that I’m not even very good at scheduling things for work, but then I quickly vowed to do better with both.

I tried to point out that even with scheduling family time, it sure seemed like he worked a lot. How did he stay fresh over such a long career? He paused, raising those animated eyebrows as he deliberated. "Vacations and sabbaticals," he finally determined. "But when you go on vacation it has to be away. In my day you were nearly always available for patient phone calls. The only way to truly be on vacation would be to go far away from phones. Unplugged.

"And then, every 5 years, I would take a 6-month sabbatical. No seeing patients. We would pack up the kids and go to London. Sometimes I would come back at 3 months to take care of a few things, but I think sabbaticals are instrumental in rejuvenating a career. I would work on other projects or write. It made things harder financially, and we had to plan for it, but I came back to my practice refreshed, and the kids learned a lot, too." He settled back into his seat, arms crossed, his smile now looking more pleased and proud than amused.

The small-group time ended and Dr. Clever took polls from the crowd. Among recurring themes were exercise, saying "no," establishing sabbatical programs with your group, and taking time to completely unplug from work – no cell phones, no e-mail.

As the hour came to a close and the crowd shuffled for the exit, I felt that our small-group connection was too important to just say goodbye abruptly. I should get their contact information, I thought, so I can let them know how I am doing with my work-life balance, my sabbaticals, my scheduled time. But I didn’t, and instead watched the couple, hands held, walk down the long corridor, feeling inspired and hopeful that I too could maybe be successful in both career and family.

And so it is that I have written this column many days before it is due (a first for me) so that I can go on vacation. I’m going far away from cell phone access and e-mail. I must admit, there is a little trepidation in the thought of being so disconnected. But, after watching me spend all of Christmas eve working on a research paper, my wife is delighted at any kind of improvement in my work-life balance. That nameless couple would be proud.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July 2013, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

I went to the American College of Physicians meeting in Orlando this year and attended a meeting about balancing life and work. Seems a little early in my career for such self-help I know, but I’ve always been a little too self-aware.

The speaker was Linda Clever, an internist and professor at the University of California, San Francisco, who is also a dynamic woman who has written books on living life with a busy career. The 1-hour group discussion was a nice change of pace in a conference full of experts talking about guidelines. I sat down next to an older couple as I settled in for the hour, delighted there was not a PowerPoint in sight. We were quickly asked to break into small groups to talk about strategies for avoiding burnout; my group ended up being me, and the couple.

©redkoala/fotolia.com

They must have been in their 70s, maybe even 80s, both retired. He had been a neurologist for more than 40 years (in his day neurology was part of internal medicine, thus his presence at ACP), and she had been a journalist. It seemed fitting that here I was, in my first year as an attending, looking forward into a career and unclear exactly where it was headed, filled with uncertainty; and there they were, an entire career and life behind them, comfortable and confident for the ride they had had. We got started.

I asked them what they had done to try and maintain balance, to have a life amongst a career, or rather a career amongst a life. The wife, short and plump with round thin-rimmed glasses tucked into white hair, could have been plucked right out of a story about the North Pole. She began to recount some of the lessons they had learned. She talked lovingly of her husband and how he was always so engaged and interested in everything and that he was always volunteering to be on this committee or that committee. He sat smiling with big, bushy, white eyebrows, clean-shaven face with a yellow short-sleeve dress shirt and a red and blue tie that hung 2 or 3 inches above his belt. Short like his wife, his legs seemed to swing back and forth under the chair like a child at a playground.

"It always was interesting!" he exclaimed, waving his hands in excitement. "To me it never felt like work. Even in medical school I wanted to be involved in anything."

I thought back to my own days of medical school, involved in or leading multiple activist groups, often to the detriment of grades, and now my already growing list of committees and "nonclinical" activities.

"Once we had children," the wife went on, "I would tell his secretary to schedule school performances and sporting events, right there in his appointment book. If we did that, he never missed an event. In fact, the kids never even knew how busy he was because he was always there. It wasn’t until they grew up that they understood how much he was juggling." His smile just pulsed into an even bigger smile, chuckling here and there as she talked. "So that would be my recommendation to you. Be deliberate about your time with your family; schedule it like you would anything else. "

I made a mental note, arguing briefly with myself that I’m not even very good at scheduling things for work, but then I quickly vowed to do better with both.

I tried to point out that even with scheduling family time, it sure seemed like he worked a lot. How did he stay fresh over such a long career? He paused, raising those animated eyebrows as he deliberated. "Vacations and sabbaticals," he finally determined. "But when you go on vacation it has to be away. In my day you were nearly always available for patient phone calls. The only way to truly be on vacation would be to go far away from phones. Unplugged.

"And then, every 5 years, I would take a 6-month sabbatical. No seeing patients. We would pack up the kids and go to London. Sometimes I would come back at 3 months to take care of a few things, but I think sabbaticals are instrumental in rejuvenating a career. I would work on other projects or write. It made things harder financially, and we had to plan for it, but I came back to my practice refreshed, and the kids learned a lot, too." He settled back into his seat, arms crossed, his smile now looking more pleased and proud than amused.

The small-group time ended and Dr. Clever took polls from the crowd. Among recurring themes were exercise, saying "no," establishing sabbatical programs with your group, and taking time to completely unplug from work – no cell phones, no e-mail.

As the hour came to a close and the crowd shuffled for the exit, I felt that our small-group connection was too important to just say goodbye abruptly. I should get their contact information, I thought, so I can let them know how I am doing with my work-life balance, my sabbaticals, my scheduled time. But I didn’t, and instead watched the couple, hands held, walk down the long corridor, feeling inspired and hopeful that I too could maybe be successful in both career and family.

And so it is that I have written this column many days before it is due (a first for me) so that I can go on vacation. I’m going far away from cell phone access and e-mail. I must admit, there is a little trepidation in the thought of being so disconnected. But, after watching me spend all of Christmas eve working on a research paper, my wife is delighted at any kind of improvement in my work-life balance. That nameless couple would be proud.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July 2013, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

I went to the American College of Physicians meeting in Orlando this year and attended a meeting about balancing life and work. Seems a little early in my career for such self-help I know, but I’ve always been a little too self-aware.

The speaker was Linda Clever, an internist and professor at the University of California, San Francisco, who is also a dynamic woman who has written books on living life with a busy career. The 1-hour group discussion was a nice change of pace in a conference full of experts talking about guidelines. I sat down next to an older couple as I settled in for the hour, delighted there was not a PowerPoint in sight. We were quickly asked to break into small groups to talk about strategies for avoiding burnout; my group ended up being me, and the couple.

©redkoala/fotolia.com

They must have been in their 70s, maybe even 80s, both retired. He had been a neurologist for more than 40 years (in his day neurology was part of internal medicine, thus his presence at ACP), and she had been a journalist. It seemed fitting that here I was, in my first year as an attending, looking forward into a career and unclear exactly where it was headed, filled with uncertainty; and there they were, an entire career and life behind them, comfortable and confident for the ride they had had. We got started.

I asked them what they had done to try and maintain balance, to have a life amongst a career, or rather a career amongst a life. The wife, short and plump with round thin-rimmed glasses tucked into white hair, could have been plucked right out of a story about the North Pole. She began to recount some of the lessons they had learned. She talked lovingly of her husband and how he was always so engaged and interested in everything and that he was always volunteering to be on this committee or that committee. He sat smiling with big, bushy, white eyebrows, clean-shaven face with a yellow short-sleeve dress shirt and a red and blue tie that hung 2 or 3 inches above his belt. Short like his wife, his legs seemed to swing back and forth under the chair like a child at a playground.

"It always was interesting!" he exclaimed, waving his hands in excitement. "To me it never felt like work. Even in medical school I wanted to be involved in anything."

I thought back to my own days of medical school, involved in or leading multiple activist groups, often to the detriment of grades, and now my already growing list of committees and "nonclinical" activities.

"Once we had children," the wife went on, "I would tell his secretary to schedule school performances and sporting events, right there in his appointment book. If we did that, he never missed an event. In fact, the kids never even knew how busy he was because he was always there. It wasn’t until they grew up that they understood how much he was juggling." His smile just pulsed into an even bigger smile, chuckling here and there as she talked. "So that would be my recommendation to you. Be deliberate about your time with your family; schedule it like you would anything else. "

I made a mental note, arguing briefly with myself that I’m not even very good at scheduling things for work, but then I quickly vowed to do better with both.

I tried to point out that even with scheduling family time, it sure seemed like he worked a lot. How did he stay fresh over such a long career? He paused, raising those animated eyebrows as he deliberated. "Vacations and sabbaticals," he finally determined. "But when you go on vacation it has to be away. In my day you were nearly always available for patient phone calls. The only way to truly be on vacation would be to go far away from phones. Unplugged.

"And then, every 5 years, I would take a 6-month sabbatical. No seeing patients. We would pack up the kids and go to London. Sometimes I would come back at 3 months to take care of a few things, but I think sabbaticals are instrumental in rejuvenating a career. I would work on other projects or write. It made things harder financially, and we had to plan for it, but I came back to my practice refreshed, and the kids learned a lot, too." He settled back into his seat, arms crossed, his smile now looking more pleased and proud than amused.

The small-group time ended and Dr. Clever took polls from the crowd. Among recurring themes were exercise, saying "no," establishing sabbatical programs with your group, and taking time to completely unplug from work – no cell phones, no e-mail.

As the hour came to a close and the crowd shuffled for the exit, I felt that our small-group connection was too important to just say goodbye abruptly. I should get their contact information, I thought, so I can let them know how I am doing with my work-life balance, my sabbaticals, my scheduled time. But I didn’t, and instead watched the couple, hands held, walk down the long corridor, feeling inspired and hopeful that I too could maybe be successful in both career and family.

And so it is that I have written this column many days before it is due (a first for me) so that I can go on vacation. I’m going far away from cell phone access and e-mail. I must admit, there is a little trepidation in the thought of being so disconnected. But, after watching me spend all of Christmas eve working on a research paper, my wife is delighted at any kind of improvement in my work-life balance. That nameless couple would be proud.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July 2013, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

Death is no stranger to me. Like many my age, I have lost all my grandparents, but I also lost my dad early, when I was only 18. In my early 20s I saw death hundreds of times as an assistant to the medical examiner. Now, as part of my job, I routinely help families and patients approach this last and final stage of life.

Despite this familiarity, I somehow forget what the cold, harsh finality of death personally feels like; the incomprehensible irreversibility, the eerie emptiness. Patients often pass during the night, leaving me to find, the next day, their name off my list and their room being cleaned. I sign the death certificate and move on. It is, after all, part of my job.

Now and then death will touch me directly, and I am reminded anew what it is really like, beyond a "goals of care discussion" and a death certificate.

First there is the stunned knot in the stomach when you first hear the news; the pit of lost words and imploded emotions. Then comes the sadness followed by the unexpected and surreal work that has to be done. Emotions are briefly put on hold to "get things in order." Then, when all is said and done, you have to return to the empty nuances of life: work, bills, chores. You walk through the motions, trying to act the same. The world goes on.

©Nneirda/thinkstockphotos.com

Today I woke up to find that my friend and pet of 8 years had died in her sleep. She had been battling infections for a year and a half, had become incontinent, and was losing weight. I knew it was coming, I just didn’t know when. In evenings, I would find myself taking pause to look for respirations when she would rest in the shade. Then today, a day no different from any other, it just happened. Of course I knew instantly; there is such an indescribable difference between a lifeless body and one who still has even shallow breath. I just stood and stared. I told my wife and I watched the same helpless feelings pour over her.

This loyal rabbit, our friend, had been with me since I rescued her during medical school. At the time, I was not keen on owning any animal, let alone a little rabbit. But she needed rescuing and thus I adopted her. Then, through the loneliness of medical school clerkships and residency, she became my friend, often my only friend. She was a faithful companion that ran circles around my feet when I would come in the door after 30-hour shifts, and she would curl up next to me during post-call Netflix naps. When my wife moved to the United States in the middle of my residency, she was often her only companion for days at a time as I worked long hours in the ICU. She was with me through every relentless minute of studying for boards, sleeping quietly at my feet.

After we had a good cry came the cold requisite to "get things in order." We said our final good-byes just 2 hours ago, and we returned to the empty nuances of life: Fix the leaking faucet, eat dinner, do the dishes.

Working with patients who are sick and nearing the end of their lives can be part of our rhythm – monthly, weekly, or even daily. But for the patient and family, there is nothing rhythmic about it; death is a life event, perhaps the life event.

Quality of care can mean creating a temporal space of peace and honor, no matter the loss and however brief, that has a different tone from the rest of our day. It means never suggesting in word or deed that we are too busy to recognize the emptiness that the death will leave behind. It is understanding the initial thud that a palliative care/hospice referral makes on a loved-one’s soul. Even a novice physician or nurse should pause in recognition that though the hospital bed will be refilled and the hospital workload will continue, for families, nothing is ever quite the same.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July 2013, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

Death is no stranger to me. Like many my age, I have lost all my grandparents, but I also lost my dad early, when I was only 18. In my early 20s I saw death hundreds of times as an assistant to the medical examiner. Now, as part of my job, I routinely help families and patients approach this last and final stage of life.

Despite this familiarity, I somehow forget what the cold, harsh finality of death personally feels like; the incomprehensible irreversibility, the eerie emptiness. Patients often pass during the night, leaving me to find, the next day, their name off my list and their room being cleaned. I sign the death certificate and move on. It is, after all, part of my job.

Now and then death will touch me directly, and I am reminded anew what it is really like, beyond a "goals of care discussion" and a death certificate.

First there is the stunned knot in the stomach when you first hear the news; the pit of lost words and imploded emotions. Then comes the sadness followed by the unexpected and surreal work that has to be done. Emotions are briefly put on hold to "get things in order." Then, when all is said and done, you have to return to the empty nuances of life: work, bills, chores. You walk through the motions, trying to act the same. The world goes on.

©Nneirda/thinkstockphotos.com

Today I woke up to find that my friend and pet of 8 years had died in her sleep. She had been battling infections for a year and a half, had become incontinent, and was losing weight. I knew it was coming, I just didn’t know when. In evenings, I would find myself taking pause to look for respirations when she would rest in the shade. Then today, a day no different from any other, it just happened. Of course I knew instantly; there is such an indescribable difference between a lifeless body and one who still has even shallow breath. I just stood and stared. I told my wife and I watched the same helpless feelings pour over her.

This loyal rabbit, our friend, had been with me since I rescued her during medical school. At the time, I was not keen on owning any animal, let alone a little rabbit. But she needed rescuing and thus I adopted her. Then, through the loneliness of medical school clerkships and residency, she became my friend, often my only friend. She was a faithful companion that ran circles around my feet when I would come in the door after 30-hour shifts, and she would curl up next to me during post-call Netflix naps. When my wife moved to the United States in the middle of my residency, she was often her only companion for days at a time as I worked long hours in the ICU. She was with me through every relentless minute of studying for boards, sleeping quietly at my feet.

After we had a good cry came the cold requisite to "get things in order." We said our final good-byes just 2 hours ago, and we returned to the empty nuances of life: Fix the leaking faucet, eat dinner, do the dishes.

Working with patients who are sick and nearing the end of their lives can be part of our rhythm – monthly, weekly, or even daily. But for the patient and family, there is nothing rhythmic about it; death is a life event, perhaps the life event.

Quality of care can mean creating a temporal space of peace and honor, no matter the loss and however brief, that has a different tone from the rest of our day. It means never suggesting in word or deed that we are too busy to recognize the emptiness that the death will leave behind. It is understanding the initial thud that a palliative care/hospice referral makes on a loved-one’s soul. Even a novice physician or nurse should pause in recognition that though the hospital bed will be refilled and the hospital workload will continue, for families, nothing is ever quite the same.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July 2013, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

Death is no stranger to me. Like many my age, I have lost all my grandparents, but I also lost my dad early, when I was only 18. In my early 20s I saw death hundreds of times as an assistant to the medical examiner. Now, as part of my job, I routinely help families and patients approach this last and final stage of life.

Despite this familiarity, I somehow forget what the cold, harsh finality of death personally feels like; the incomprehensible irreversibility, the eerie emptiness. Patients often pass during the night, leaving me to find, the next day, their name off my list and their room being cleaned. I sign the death certificate and move on. It is, after all, part of my job.

Now and then death will touch me directly, and I am reminded anew what it is really like, beyond a "goals of care discussion" and a death certificate.

First there is the stunned knot in the stomach when you first hear the news; the pit of lost words and imploded emotions. Then comes the sadness followed by the unexpected and surreal work that has to be done. Emotions are briefly put on hold to "get things in order." Then, when all is said and done, you have to return to the empty nuances of life: work, bills, chores. You walk through the motions, trying to act the same. The world goes on.

©Nneirda/thinkstockphotos.com

Today I woke up to find that my friend and pet of 8 years had died in her sleep. She had been battling infections for a year and a half, had become incontinent, and was losing weight. I knew it was coming, I just didn’t know when. In evenings, I would find myself taking pause to look for respirations when she would rest in the shade. Then today, a day no different from any other, it just happened. Of course I knew instantly; there is such an indescribable difference between a lifeless body and one who still has even shallow breath. I just stood and stared. I told my wife and I watched the same helpless feelings pour over her.

This loyal rabbit, our friend, had been with me since I rescued her during medical school. At the time, I was not keen on owning any animal, let alone a little rabbit. But she needed rescuing and thus I adopted her. Then, through the loneliness of medical school clerkships and residency, she became my friend, often my only friend. She was a faithful companion that ran circles around my feet when I would come in the door after 30-hour shifts, and she would curl up next to me during post-call Netflix naps. When my wife moved to the United States in the middle of my residency, she was often her only companion for days at a time as I worked long hours in the ICU. She was with me through every relentless minute of studying for boards, sleeping quietly at my feet.

After we had a good cry came the cold requisite to "get things in order." We said our final good-byes just 2 hours ago, and we returned to the empty nuances of life: Fix the leaking faucet, eat dinner, do the dishes.

Working with patients who are sick and nearing the end of their lives can be part of our rhythm – monthly, weekly, or even daily. But for the patient and family, there is nothing rhythmic about it; death is a life event, perhaps the life event.

Quality of care can mean creating a temporal space of peace and honor, no matter the loss and however brief, that has a different tone from the rest of our day. It means never suggesting in word or deed that we are too busy to recognize the emptiness that the death will leave behind. It is understanding the initial thud that a palliative care/hospice referral makes on a loved-one’s soul. Even a novice physician or nurse should pause in recognition that though the hospital bed will be refilled and the hospital workload will continue, for families, nothing is ever quite the same.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July 2013, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

As I reflect on my 1 year of writing for this newspaper and my first year as an attending, some things stand out as being, for me, consistently challenging and others, consistently rewarding. Time has seemed to go by much faster than during residency. So, without further ado, here is a list of those things that I have, continue to, and may always either struggle with or find joy in.

The checkout e-mail

What I feared the most about becoming an attending – managing a team day to day and teaching students and residents – has come easier than I thought. What has brought me the most angst, however, is passing my team off to my partners. As I write my "checkout e-mail," I am often plagued by doubt and worry that I have overlooked something. I worry I have ordered too many/not enough studies, consulted too often/not enough, or discharged too early/not early enough.

For the first half, and most emotionally pathologic part, of the year, I would log in each day after coming off-service, to see how my partners had changed things, to see what I had missed, and to see how the patients were progressing. I would even text my partners and residents to "see how Mr. X is doing" or to ask "How is the team doing?" This would often result in me second-guessing myself and ruining my day off. I don’t do this anymore.

Now I give myself several healthy days of "no team contact" before I log in to finish notes and inevitably check in on patients. I know that there must be a balance of educational follow-up, feedback, and a healthy forgiving mind, but I still struggle to find it.

Placement

Though there are some scoring systems that help the clinician know which patients need to be hospitalized, who needs the ICU, and who can go home, a lot of this falls in evidence-based medicine’s gray zone. One of the learning curves for me was to know which patients I should insist go to the unit, insist be evaluated by the unit, or who, though sick, can be managed on the floor. In the end, I have found that my gut feeling and the first 15 seconds of my encounter with the patient help me more with placement than any scoring system or guideline.

The consult

It has been a bit painful learning to juggle the nuances of consultant services preferences (who always wants to be involved vs. who rarely does), attending preferences (some want to know when any of their patients are in-house), and what is my own comfort level. I think, for the most part, I have erred on the overconsult side this year, and though I have felt embarrassed a couple of times, it has been the safer route as I become comfortable as a hospitalist.

Discharge

As with The Placement, there is virtually no evidence to help The Discharge. As a resident, an earlier discharge usually was better, but as an attending, The Discharge is where the complex intertwinement of disease, social situation, physical therapy, and unfortunately, day of the week manifests (see previous column: "Closed on weekends?" Hospitalist News, May 2014). Also, like The Placement, this often ends up being a gut feeling supported by close follow-up, a good conversation with the patient and family, and some hopeful finger-crossing.

Being a people pleaser

This personality trait has helped me to be a good student, a responsive employee, and sometimes a good doctor. But it has also caused me a good amount of suffering. Thus, when despite my best efforts a patient or family continues to be upset with how quickly or slowly things are being done, which services are or are not involved, etc., I feel bad. Maybe this will change in the coming years. Maybe not.

Teaching

I have always liked teaching, but as a resident this often played second fiddle to grunt work and "res-interning." As an attending, however, I have finally been able to make this a significant part of every day. I enjoy it, and I think my residents and medical students enjoy that I enjoy it. This has been one of the true pleasures of my first year as an attending.

Connection

As an attending I now benefit from much more time to enjoy my patient connections. Less tired and harried, I have longer conversations and enjoy actively practicing communication. I have the ability to have more in-depth conversations about goals of care, and have found that often these conversations end with a decrease in anxiety and a sense of peace.

I now also have a business card with an e-mail address that receives occasional thank-you notes. Yesterday, I received an e-mail that said simply, "Thank you for your great service." How incredibly fulfilling. Talk about unexpected joy.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July 2013, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

As I reflect on my 1 year of writing for this newspaper and my first year as an attending, some things stand out as being, for me, consistently challenging and others, consistently rewarding. Time has seemed to go by much faster than during residency. So, without further ado, here is a list of those things that I have, continue to, and may always either struggle with or find joy in.

The checkout e-mail

What I feared the most about becoming an attending – managing a team day to day and teaching students and residents – has come easier than I thought. What has brought me the most angst, however, is passing my team off to my partners. As I write my "checkout e-mail," I am often plagued by doubt and worry that I have overlooked something. I worry I have ordered too many/not enough studies, consulted too often/not enough, or discharged too early/not early enough.

For the first half, and most emotionally pathologic part, of the year, I would log in each day after coming off-service, to see how my partners had changed things, to see what I had missed, and to see how the patients were progressing. I would even text my partners and residents to "see how Mr. X is doing" or to ask "How is the team doing?" This would often result in me second-guessing myself and ruining my day off. I don’t do this anymore.

Now I give myself several healthy days of "no team contact" before I log in to finish notes and inevitably check in on patients. I know that there must be a balance of educational follow-up, feedback, and a healthy forgiving mind, but I still struggle to find it.

Placement

Though there are some scoring systems that help the clinician know which patients need to be hospitalized, who needs the ICU, and who can go home, a lot of this falls in evidence-based medicine’s gray zone. One of the learning curves for me was to know which patients I should insist go to the unit, insist be evaluated by the unit, or who, though sick, can be managed on the floor. In the end, I have found that my gut feeling and the first 15 seconds of my encounter with the patient help me more with placement than any scoring system or guideline.

The consult

It has been a bit painful learning to juggle the nuances of consultant services preferences (who always wants to be involved vs. who rarely does), attending preferences (some want to know when any of their patients are in-house), and what is my own comfort level. I think, for the most part, I have erred on the overconsult side this year, and though I have felt embarrassed a couple of times, it has been the safer route as I become comfortable as a hospitalist.

Discharge

As with The Placement, there is virtually no evidence to help The Discharge. As a resident, an earlier discharge usually was better, but as an attending, The Discharge is where the complex intertwinement of disease, social situation, physical therapy, and unfortunately, day of the week manifests (see previous column: "Closed on weekends?" Hospitalist News, May 2014). Also, like The Placement, this often ends up being a gut feeling supported by close follow-up, a good conversation with the patient and family, and some hopeful finger-crossing.

Being a people pleaser

This personality trait has helped me to be a good student, a responsive employee, and sometimes a good doctor. But it has also caused me a good amount of suffering. Thus, when despite my best efforts a patient or family continues to be upset with how quickly or slowly things are being done, which services are or are not involved, etc., I feel bad. Maybe this will change in the coming years. Maybe not.

Teaching

I have always liked teaching, but as a resident this often played second fiddle to grunt work and "res-interning." As an attending, however, I have finally been able to make this a significant part of every day. I enjoy it, and I think my residents and medical students enjoy that I enjoy it. This has been one of the true pleasures of my first year as an attending.

Connection

As an attending I now benefit from much more time to enjoy my patient connections. Less tired and harried, I have longer conversations and enjoy actively practicing communication. I have the ability to have more in-depth conversations about goals of care, and have found that often these conversations end with a decrease in anxiety and a sense of peace.

I now also have a business card with an e-mail address that receives occasional thank-you notes. Yesterday, I received an e-mail that said simply, "Thank you for your great service." How incredibly fulfilling. Talk about unexpected joy.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July 2013, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

As I reflect on my 1 year of writing for this newspaper and my first year as an attending, some things stand out as being, for me, consistently challenging and others, consistently rewarding. Time has seemed to go by much faster than during residency. So, without further ado, here is a list of those things that I have, continue to, and may always either struggle with or find joy in.

The checkout e-mail

What I feared the most about becoming an attending – managing a team day to day and teaching students and residents – has come easier than I thought. What has brought me the most angst, however, is passing my team off to my partners. As I write my "checkout e-mail," I am often plagued by doubt and worry that I have overlooked something. I worry I have ordered too many/not enough studies, consulted too often/not enough, or discharged too early/not early enough.

For the first half, and most emotionally pathologic part, of the year, I would log in each day after coming off-service, to see how my partners had changed things, to see what I had missed, and to see how the patients were progressing. I would even text my partners and residents to "see how Mr. X is doing" or to ask "How is the team doing?" This would often result in me second-guessing myself and ruining my day off. I don’t do this anymore.

Now I give myself several healthy days of "no team contact" before I log in to finish notes and inevitably check in on patients. I know that there must be a balance of educational follow-up, feedback, and a healthy forgiving mind, but I still struggle to find it.

Placement

Though there are some scoring systems that help the clinician know which patients need to be hospitalized, who needs the ICU, and who can go home, a lot of this falls in evidence-based medicine’s gray zone. One of the learning curves for me was to know which patients I should insist go to the unit, insist be evaluated by the unit, or who, though sick, can be managed on the floor. In the end, I have found that my gut feeling and the first 15 seconds of my encounter with the patient help me more with placement than any scoring system or guideline.

The consult

It has been a bit painful learning to juggle the nuances of consultant services preferences (who always wants to be involved vs. who rarely does), attending preferences (some want to know when any of their patients are in-house), and what is my own comfort level. I think, for the most part, I have erred on the overconsult side this year, and though I have felt embarrassed a couple of times, it has been the safer route as I become comfortable as a hospitalist.

Discharge

As with The Placement, there is virtually no evidence to help The Discharge. As a resident, an earlier discharge usually was better, but as an attending, The Discharge is where the complex intertwinement of disease, social situation, physical therapy, and unfortunately, day of the week manifests (see previous column: "Closed on weekends?" Hospitalist News, May 2014). Also, like The Placement, this often ends up being a gut feeling supported by close follow-up, a good conversation with the patient and family, and some hopeful finger-crossing.

Being a people pleaser

This personality trait has helped me to be a good student, a responsive employee, and sometimes a good doctor. But it has also caused me a good amount of suffering. Thus, when despite my best efforts a patient or family continues to be upset with how quickly or slowly things are being done, which services are or are not involved, etc., I feel bad. Maybe this will change in the coming years. Maybe not.

Teaching

I have always liked teaching, but as a resident this often played second fiddle to grunt work and "res-interning." As an attending, however, I have finally been able to make this a significant part of every day. I enjoy it, and I think my residents and medical students enjoy that I enjoy it. This has been one of the true pleasures of my first year as an attending.

Connection

As an attending I now benefit from much more time to enjoy my patient connections. Less tired and harried, I have longer conversations and enjoy actively practicing communication. I have the ability to have more in-depth conversations about goals of care, and have found that often these conversations end with a decrease in anxiety and a sense of peace.

I now also have a business card with an e-mail address that receives occasional thank-you notes. Yesterday, I received an e-mail that said simply, "Thank you for your great service." How incredibly fulfilling. Talk about unexpected joy.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July 2013, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

Nearly a year after "starting out" on the inpatient wards as a new hospitalist, there has been one idiosyncrasy that I just can’t seem to understand: Hospitals and skilled nursing facilities decrease their staffing and services on the weekends. Though I was aware of this as a resident, because it was frustrating, now, as an attending, it’s nearly surreal. I am the one responsible for the length of stay, patient satisfaction scores, and health care cost savings, and it just doesn’t make sense to decrease available services because of the weekend. How can it be good for patient care?

While Saturdays and Sundays can be slower from an admitting standpoint, because there is no clinic activity to generate a percentage of admissions, Friday night is often one of the busiest admitting nights of the week; and those patients admitted then, along with everyone else who failed to discharge during the week, have to be cared for on the weekend. If there are sick patients, there should be services for those patients. This means that PICC teams, wound care, PT/OT, nutrition, MRI staff, consultant services, case managers, and even hospitalists should treat Saturday and Sunday like any other day, and that staffing should reflect that. How can I as a hospitalist meet the goals of the system and take care of the patient if I don’t have the resources?

©robuart/Thinkstock

What usually happens is that providers "cover" for each other, which in my opinion, leads to more stressed-out staff, decreased time spent with patients, and decreased quality of care. I bet patients can sense it. Consultants who are spread thin are more likely to bark at each other, and things are triaged to what can "wait until Monday." For the inpatient, should anything wait until Monday?

I think nothing is as compromised, from a hospitalist standpoint, as case management and discharge capabilities. On the hospital and skilled nursing facility sides, the stress and complexity of discharge situation drastically increases on the weekends, yet case management is reduced by more than half. Is it fair or even safe for patients to stay another expensive night in the hospital simply because it is a weekend or a holiday? As Fridays approach, I find myself planning discharges around the looming weekend. Sometimes, I am faced with choosing to either rush things to prepare for the Friday discharge or accepting that discharge will simply have to wait until Monday.

I suppose there are many reasons the system is the way it is, but the biggest factor, as always, is likely money.

Days off have to come from somewhere and if another provider is not going to "cover," the only other option is to hire more case managers, more hospitalists, more fellows, and more ancillary staff for PICC lines, physical therapy, MRIs, wound consults, and transition of care.

In the end, if our goals truly are to increase patient satisfaction, decrease complications, decrease length of stay, and decrease patient frustration, then we should start thinking of our inpatient health care system like we would the fire department or even Walmart: open and fully staffed 365 days a year. Because illness, like fire and capitalism, doesn’t take the weekend off.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

Nearly a year after "starting out" on the inpatient wards as a new hospitalist, there has been one idiosyncrasy that I just can’t seem to understand: Hospitals and skilled nursing facilities decrease their staffing and services on the weekends. Though I was aware of this as a resident, because it was frustrating, now, as an attending, it’s nearly surreal. I am the one responsible for the length of stay, patient satisfaction scores, and health care cost savings, and it just doesn’t make sense to decrease available services because of the weekend. How can it be good for patient care?

While Saturdays and Sundays can be slower from an admitting standpoint, because there is no clinic activity to generate a percentage of admissions, Friday night is often one of the busiest admitting nights of the week; and those patients admitted then, along with everyone else who failed to discharge during the week, have to be cared for on the weekend. If there are sick patients, there should be services for those patients. This means that PICC teams, wound care, PT/OT, nutrition, MRI staff, consultant services, case managers, and even hospitalists should treat Saturday and Sunday like any other day, and that staffing should reflect that. How can I as a hospitalist meet the goals of the system and take care of the patient if I don’t have the resources?

©robuart/Thinkstock

What usually happens is that providers "cover" for each other, which in my opinion, leads to more stressed-out staff, decreased time spent with patients, and decreased quality of care. I bet patients can sense it. Consultants who are spread thin are more likely to bark at each other, and things are triaged to what can "wait until Monday." For the inpatient, should anything wait until Monday?

I think nothing is as compromised, from a hospitalist standpoint, as case management and discharge capabilities. On the hospital and skilled nursing facility sides, the stress and complexity of discharge situation drastically increases on the weekends, yet case management is reduced by more than half. Is it fair or even safe for patients to stay another expensive night in the hospital simply because it is a weekend or a holiday? As Fridays approach, I find myself planning discharges around the looming weekend. Sometimes, I am faced with choosing to either rush things to prepare for the Friday discharge or accepting that discharge will simply have to wait until Monday.

I suppose there are many reasons the system is the way it is, but the biggest factor, as always, is likely money.

Days off have to come from somewhere and if another provider is not going to "cover," the only other option is to hire more case managers, more hospitalists, more fellows, and more ancillary staff for PICC lines, physical therapy, MRIs, wound consults, and transition of care.

In the end, if our goals truly are to increase patient satisfaction, decrease complications, decrease length of stay, and decrease patient frustration, then we should start thinking of our inpatient health care system like we would the fire department or even Walmart: open and fully staffed 365 days a year. Because illness, like fire and capitalism, doesn’t take the weekend off.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

Nearly a year after "starting out" on the inpatient wards as a new hospitalist, there has been one idiosyncrasy that I just can’t seem to understand: Hospitals and skilled nursing facilities decrease their staffing and services on the weekends. Though I was aware of this as a resident, because it was frustrating, now, as an attending, it’s nearly surreal. I am the one responsible for the length of stay, patient satisfaction scores, and health care cost savings, and it just doesn’t make sense to decrease available services because of the weekend. How can it be good for patient care?

While Saturdays and Sundays can be slower from an admitting standpoint, because there is no clinic activity to generate a percentage of admissions, Friday night is often one of the busiest admitting nights of the week; and those patients admitted then, along with everyone else who failed to discharge during the week, have to be cared for on the weekend. If there are sick patients, there should be services for those patients. This means that PICC teams, wound care, PT/OT, nutrition, MRI staff, consultant services, case managers, and even hospitalists should treat Saturday and Sunday like any other day, and that staffing should reflect that. How can I as a hospitalist meet the goals of the system and take care of the patient if I don’t have the resources?

©robuart/Thinkstock

What usually happens is that providers "cover" for each other, which in my opinion, leads to more stressed-out staff, decreased time spent with patients, and decreased quality of care. I bet patients can sense it. Consultants who are spread thin are more likely to bark at each other, and things are triaged to what can "wait until Monday." For the inpatient, should anything wait until Monday?

I think nothing is as compromised, from a hospitalist standpoint, as case management and discharge capabilities. On the hospital and skilled nursing facility sides, the stress and complexity of discharge situation drastically increases on the weekends, yet case management is reduced by more than half. Is it fair or even safe for patients to stay another expensive night in the hospital simply because it is a weekend or a holiday? As Fridays approach, I find myself planning discharges around the looming weekend. Sometimes, I am faced with choosing to either rush things to prepare for the Friday discharge or accepting that discharge will simply have to wait until Monday.

I suppose there are many reasons the system is the way it is, but the biggest factor, as always, is likely money.

Days off have to come from somewhere and if another provider is not going to "cover," the only other option is to hire more case managers, more hospitalists, more fellows, and more ancillary staff for PICC lines, physical therapy, MRIs, wound consults, and transition of care.

In the end, if our goals truly are to increase patient satisfaction, decrease complications, decrease length of stay, and decrease patient frustration, then we should start thinking of our inpatient health care system like we would the fire department or even Walmart: open and fully staffed 365 days a year. Because illness, like fire and capitalism, doesn’t take the weekend off.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July, and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

A medical school professor once told me that if power plant engineers were to evaluate health care systems, they would be appalled. I was reminded of this during the Hospitalist Medicine 2014 conference in Las Vegas, not by one of the classes, but by "Ka."

I have seen this Cirque du Soleil show several times, and it is breathtaking. This time, I had the opportunity to go with several of my hospitalist group partners and take a backstage tour; it was as impressive as the show itself. With 15 stories of cables, springs, walkways, and pulleys, and with seven moving stages, it looked more like a city than a theatre. Our guide, also a performer, told us that during the show this circus city is a blur of complicated activity with hundreds of staff ensuring the safety of dozens of performers doing jaw-dropping stunts. There are backup plans to the backup plans. There is real-time communication with the performers regarding equipment malfunctions, delays, etc., allowing the artists to adjust and change the performance if something has become unsafe. As we left the tour, our quality improvement guru uttered simply: "Why can’t we obtain this kind of quality in health care?"

© Tomas Muscionico

Cirque du Soleil has been pushing the limits of acrobatics for 30 years with only one accident resulting in death. Compare that with medicine, where data extrapolated from the seminal Institute of Medicine report in 1999 suggested that hospital-based medical errors were the eighth-leading cause of death in the United States.

That being said, health care has come a long way in the last decade, but it has likely been the result of looking to other safety-oriented industries. The most well-known is the aviation industry’s influence of checklists in the operating room (see the 2009 book "The Checklist Manifesto: How to Get Things Right"), though this has now become a theme in medial ICUs too, where we see checklists, protocols, performance audits, and bundles. Though order sets have tried to protocolize some floor-based treatment plans, checklists and bundles have yet to truly become part of our culture.

Just like that human element that only the artists of Ka can provide, the thought process of the physician will always be needed in medicine. But change is coming, and like the surgeons and intensivists before us, I think it will be in the form of checklists, protocols, and bundles. While some of us may resist, hopefully it will ultimately make our own circus just a little bit safer.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July 2013 and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

A medical school professor once told me that if power plant engineers were to evaluate health care systems, they would be appalled. I was reminded of this during the Hospitalist Medicine 2014 conference in Las Vegas, not by one of the classes, but by "Ka."

I have seen this Cirque du Soleil show several times, and it is breathtaking. This time, I had the opportunity to go with several of my hospitalist group partners and take a backstage tour; it was as impressive as the show itself. With 15 stories of cables, springs, walkways, and pulleys, and with seven moving stages, it looked more like a city than a theatre. Our guide, also a performer, told us that during the show this circus city is a blur of complicated activity with hundreds of staff ensuring the safety of dozens of performers doing jaw-dropping stunts. There are backup plans to the backup plans. There is real-time communication with the performers regarding equipment malfunctions, delays, etc., allowing the artists to adjust and change the performance if something has become unsafe. As we left the tour, our quality improvement guru uttered simply: "Why can’t we obtain this kind of quality in health care?"

© Tomas Muscionico

Cirque du Soleil has been pushing the limits of acrobatics for 30 years with only one accident resulting in death. Compare that with medicine, where data extrapolated from the seminal Institute of Medicine report in 1999 suggested that hospital-based medical errors were the eighth-leading cause of death in the United States.

That being said, health care has come a long way in the last decade, but it has likely been the result of looking to other safety-oriented industries. The most well-known is the aviation industry’s influence of checklists in the operating room (see the 2009 book "The Checklist Manifesto: How to Get Things Right"), though this has now become a theme in medial ICUs too, where we see checklists, protocols, performance audits, and bundles. Though order sets have tried to protocolize some floor-based treatment plans, checklists and bundles have yet to truly become part of our culture.

Just like that human element that only the artists of Ka can provide, the thought process of the physician will always be needed in medicine. But change is coming, and like the surgeons and intensivists before us, I think it will be in the form of checklists, protocols, and bundles. While some of us may resist, hopefully it will ultimately make our own circus just a little bit safer.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July 2013 and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

A medical school professor once told me that if power plant engineers were to evaluate health care systems, they would be appalled. I was reminded of this during the Hospitalist Medicine 2014 conference in Las Vegas, not by one of the classes, but by "Ka."

I have seen this Cirque du Soleil show several times, and it is breathtaking. This time, I had the opportunity to go with several of my hospitalist group partners and take a backstage tour; it was as impressive as the show itself. With 15 stories of cables, springs, walkways, and pulleys, and with seven moving stages, it looked more like a city than a theatre. Our guide, also a performer, told us that during the show this circus city is a blur of complicated activity with hundreds of staff ensuring the safety of dozens of performers doing jaw-dropping stunts. There are backup plans to the backup plans. There is real-time communication with the performers regarding equipment malfunctions, delays, etc., allowing the artists to adjust and change the performance if something has become unsafe. As we left the tour, our quality improvement guru uttered simply: "Why can’t we obtain this kind of quality in health care?"

© Tomas Muscionico

Cirque du Soleil has been pushing the limits of acrobatics for 30 years with only one accident resulting in death. Compare that with medicine, where data extrapolated from the seminal Institute of Medicine report in 1999 suggested that hospital-based medical errors were the eighth-leading cause of death in the United States.

That being said, health care has come a long way in the last decade, but it has likely been the result of looking to other safety-oriented industries. The most well-known is the aviation industry’s influence of checklists in the operating room (see the 2009 book "The Checklist Manifesto: How to Get Things Right"), though this has now become a theme in medial ICUs too, where we see checklists, protocols, performance audits, and bundles. Though order sets have tried to protocolize some floor-based treatment plans, checklists and bundles have yet to truly become part of our culture.

Just like that human element that only the artists of Ka can provide, the thought process of the physician will always be needed in medicine. But change is coming, and like the surgeons and intensivists before us, I think it will be in the form of checklists, protocols, and bundles. While some of us may resist, hopefully it will ultimately make our own circus just a little bit safer.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July 2013 and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

The Hospital Consumer Assessment of Healthcare Providers and Systems is a term I was not familiar with during residency. But now, as an attending, HCAHPS is not only familiar to me but it is – rightly or wrongly – top of mind in nearly every patient encounter I have.

The jury may still be out on whether patient satisfaction is correlated with outcomes, but all things considered, I think it is a totally reasonable goal for the majority of patients. And therein lies the rub: that "minority" of patients for whom the quest for patient satisfaction scores was lost before it even began.

©greycloud/thinkstockphotos.com

Like pain management, patient satisfaction can and should be a goal for most patients. I would want it for my own family members. The problem is, there always seem (key word, seem) to be 1 or 2 on my team of about 14 patients, who need excessive amounts of time to complain, have unrealistic or perhaps pathologic goals of pain management, or who (either themselves or their family) require long explanations every day, and sometimes (though it seems like often) all three.

For the most part, these requests are reasonable; but what happens when the 1 or 2 patients begin to affect the care of the other 12?

There have been multiple days in which I have spent the most time and energy with my least sick patients. Some days, that is OK, but when it is the same patient every day for the 7-10 days that I am on service, how can I justify that time – in my mind at least – to the other patients on my team? It is not fair to them.

It is often the stoic elderly man who has a newly found mass or the women with a large effusion, whose pain and satisfaction needs I absolutely want to meet, but whom, because they complain the least may get less of me. Furthermore, it is the one or two that, over time, jade a practitioner’s mind to make the leap to the faulty mindset of "all patients are pain seekers" or "all my patients are social nightmares."

On days when I begin to feel like that, I objectively count how many patients on my list for which this is actually true. The number is small.

I am usually surprised by how the tiring encounters with the few have jaded my view of all, and this, I believe, is a pervasive problem throughout health care.

So, my question is, what should I, what should the system, do about it?

Can I tell the one or two patients, in the most polite way possible, that I only have X amount of time today because I have other sick patients I need to see? Can I tell the rude patients that they shouldn’t/can’t talk to their care team in such a manner?

Part of me says no – this is the art, these people are suffering, it is my job to listen. But again, when I see the toll they are taking on the entire staff, I think I should intervene. Because of all the time spent on the one today, there was not enough time to find disposition for the other two; they will be staying an extra night. Is that fair? Can I – and is it my job to – draw boundaries to protect my other patients, the staff, and health care resources from those one or two patients?

Do I have the right, the duty, to refuse some requests? Or is every customer always right?

What do you think? Write to [email protected] with STARTING OUT in the e-mail subject line.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

The Hospital Consumer Assessment of Healthcare Providers and Systems is a term I was not familiar with during residency. But now, as an attending, HCAHPS is not only familiar to me but it is – rightly or wrongly – top of mind in nearly every patient encounter I have.

The jury may still be out on whether patient satisfaction is correlated with outcomes, but all things considered, I think it is a totally reasonable goal for the majority of patients. And therein lies the rub: that "minority" of patients for whom the quest for patient satisfaction scores was lost before it even began.

©greycloud/thinkstockphotos.com

Like pain management, patient satisfaction can and should be a goal for most patients. I would want it for my own family members. The problem is, there always seem (key word, seem) to be 1 or 2 on my team of about 14 patients, who need excessive amounts of time to complain, have unrealistic or perhaps pathologic goals of pain management, or who (either themselves or their family) require long explanations every day, and sometimes (though it seems like often) all three.

For the most part, these requests are reasonable; but what happens when the 1 or 2 patients begin to affect the care of the other 12?

There have been multiple days in which I have spent the most time and energy with my least sick patients. Some days, that is OK, but when it is the same patient every day for the 7-10 days that I am on service, how can I justify that time – in my mind at least – to the other patients on my team? It is not fair to them.

It is often the stoic elderly man who has a newly found mass or the women with a large effusion, whose pain and satisfaction needs I absolutely want to meet, but whom, because they complain the least may get less of me. Furthermore, it is the one or two that, over time, jade a practitioner’s mind to make the leap to the faulty mindset of "all patients are pain seekers" or "all my patients are social nightmares."

On days when I begin to feel like that, I objectively count how many patients on my list for which this is actually true. The number is small.

I am usually surprised by how the tiring encounters with the few have jaded my view of all, and this, I believe, is a pervasive problem throughout health care.

So, my question is, what should I, what should the system, do about it?

Can I tell the one or two patients, in the most polite way possible, that I only have X amount of time today because I have other sick patients I need to see? Can I tell the rude patients that they shouldn’t/can’t talk to their care team in such a manner?

Part of me says no – this is the art, these people are suffering, it is my job to listen. But again, when I see the toll they are taking on the entire staff, I think I should intervene. Because of all the time spent on the one today, there was not enough time to find disposition for the other two; they will be staying an extra night. Is that fair? Can I – and is it my job to – draw boundaries to protect my other patients, the staff, and health care resources from those one or two patients?

Do I have the right, the duty, to refuse some requests? Or is every customer always right?

What do you think? Write to [email protected] with STARTING OUT in the e-mail subject line.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

The Hospital Consumer Assessment of Healthcare Providers and Systems is a term I was not familiar with during residency. But now, as an attending, HCAHPS is not only familiar to me but it is – rightly or wrongly – top of mind in nearly every patient encounter I have.

The jury may still be out on whether patient satisfaction is correlated with outcomes, but all things considered, I think it is a totally reasonable goal for the majority of patients. And therein lies the rub: that "minority" of patients for whom the quest for patient satisfaction scores was lost before it even began.

©greycloud/thinkstockphotos.com

Like pain management, patient satisfaction can and should be a goal for most patients. I would want it for my own family members. The problem is, there always seem (key word, seem) to be 1 or 2 on my team of about 14 patients, who need excessive amounts of time to complain, have unrealistic or perhaps pathologic goals of pain management, or who (either themselves or their family) require long explanations every day, and sometimes (though it seems like often) all three.

For the most part, these requests are reasonable; but what happens when the 1 or 2 patients begin to affect the care of the other 12?

There have been multiple days in which I have spent the most time and energy with my least sick patients. Some days, that is OK, but when it is the same patient every day for the 7-10 days that I am on service, how can I justify that time – in my mind at least – to the other patients on my team? It is not fair to them.

It is often the stoic elderly man who has a newly found mass or the women with a large effusion, whose pain and satisfaction needs I absolutely want to meet, but whom, because they complain the least may get less of me. Furthermore, it is the one or two that, over time, jade a practitioner’s mind to make the leap to the faulty mindset of "all patients are pain seekers" or "all my patients are social nightmares."

On days when I begin to feel like that, I objectively count how many patients on my list for which this is actually true. The number is small.

I am usually surprised by how the tiring encounters with the few have jaded my view of all, and this, I believe, is a pervasive problem throughout health care.

So, my question is, what should I, what should the system, do about it?

Can I tell the one or two patients, in the most polite way possible, that I only have X amount of time today because I have other sick patients I need to see? Can I tell the rude patients that they shouldn’t/can’t talk to their care team in such a manner?

Part of me says no – this is the art, these people are suffering, it is my job to listen. But again, when I see the toll they are taking on the entire staff, I think I should intervene. Because of all the time spent on the one today, there was not enough time to find disposition for the other two; they will be staying an extra night. Is that fair? Can I – and is it my job to – draw boundaries to protect my other patients, the staff, and health care resources from those one or two patients?

Do I have the right, the duty, to refuse some requests? Or is every customer always right?

What do you think? Write to [email protected] with STARTING OUT in the e-mail subject line.

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center, both in Salt Lake City, in July and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

Recently, I went snowshoeing with my wife and dog in West Yellowstone. The sky was so blue, the snow so white, and the scenery so perfect I had to take a picture and share it with my friends and family. No need for a fancy camera, I pulled out my cell phone, snapped a dozen photos, posted a handful on Facebook, and within seconds my friends from Mexico, Nicaragua, and Venezuela were sharing the moment with us and making comments.

Key words in the above paragraph are "sharing" and "within seconds." I was miles from a highway, hundreds and thousands of miles away from family and friends, and yet I was able to easily, instantly, share information with them.

© Aaron Amat/Fotolia.com

Another scenario: One month ago my wife was changing doctors. We arrived at her appointment and the faxed medical records had once again not "gone through." They had become lost – not scanned in, not received, not filed, or one of the many unwanted outcomes that seem to be the norm of the antiquity that is "faxing." Instead of again playing the fax game, I opted to drive across town, walk into the old clinic, pick up the medical records with my hand, and drive back to the new clinic; it took about an hour. That is how slow and unreliable I find the process of faxing.

In a profession where the communication of information and data is vital to providing care, and in an age where cost management is ever on the minds of administration, we are hamstrung by fax machines, pagers, and antiquated methods of communication from the early nineties. There was an article in The Atlantic recently about how walking into a doctor’s office was like taking a trip back in time; I can relate.

Working in a tertiary center in the intermountain West, I am often taking care of patients transferred from small hospitals in Wyoming or Montana, and it seems it is the exception rather than the rule that imaging, for example, is sent with the patient. Usually there is a report of an image, but then, as a clinician, you have to decide if you want to take the word of another doctor whom you’ve never met from a place you’ve never been regarding a patient whose life might be in danger vs. reimaging. Depending on the urgency, the latter often happens, which leads to mounting costs for the medical system to absorb and increasing exposure to unnecessary radiation.

It seems that there are two main barriers to the melding of health care and modern-day technology that even the village children in Granada, Nicaragua, carry in their front pockets: the up-front costs of buying the technology, such as EMR technology, despite the likely long-term cost savings, and HIPAA. The first could be credited to Father Capitalism, the latter to Uncle Sam.

When I imagine my ideal admitting day, it would be something like my day at Yellowstone, without the snow and blue sky. I would take a call from OSH (outside hospital), and while talking to the provider I would be getting real-time images on my PC or phone. We could talk like old friends about the subtleties seen on the imaging and the way the T waves of the EKG flow on the red, checkered paper. We would bring in our colleagues from radiology and cardiology and come to a conclusion about the most likely diagnosis and the safest place for the patient.

Gone would be the nervous anticipation of a "transfer patient" whose clinical state may or may not be consistent with the report you just received and whose medical records sent may or may not just contain a stack of nursing notes without labs, imaging, or current med list. One step further in my clinical dreamland would be something akin to what happens at my dog’s veterinary office, a virtual technological paradise. A Star Trek scanner would be waved over a chip in the abdomen of my patient and instantly onto my iPhone would appear a med list, allergies to medicine, imaging, EKGs, and different files for each hospitalization, with a wonderful H and P and DC summary for each, available at my fingertips.

I understand that this will likely never happen; just the word chip would bring up images and fears of a government-run Orwellian society to many of my patients and probably most of my family; but every time I take a picture on my iPhone and share it instantly with people half a world away, I get a warm feeling in my belly that this may one day may be a reality. A boy can dream, can’t he?

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center in Salt Lake City in July and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

Recently, I went snowshoeing with my wife and dog in West Yellowstone. The sky was so blue, the snow so white, and the scenery so perfect I had to take a picture and share it with my friends and family. No need for a fancy camera, I pulled out my cell phone, snapped a dozen photos, posted a handful on Facebook, and within seconds my friends from Mexico, Nicaragua, and Venezuela were sharing the moment with us and making comments.

Key words in the above paragraph are "sharing" and "within seconds." I was miles from a highway, hundreds and thousands of miles away from family and friends, and yet I was able to easily, instantly, share information with them.

© Aaron Amat/Fotolia.com

Another scenario: One month ago my wife was changing doctors. We arrived at her appointment and the faxed medical records had once again not "gone through." They had become lost – not scanned in, not received, not filed, or one of the many unwanted outcomes that seem to be the norm of the antiquity that is "faxing." Instead of again playing the fax game, I opted to drive across town, walk into the old clinic, pick up the medical records with my hand, and drive back to the new clinic; it took about an hour. That is how slow and unreliable I find the process of faxing.

In a profession where the communication of information and data is vital to providing care, and in an age where cost management is ever on the minds of administration, we are hamstrung by fax machines, pagers, and antiquated methods of communication from the early nineties. There was an article in The Atlantic recently about how walking into a doctor’s office was like taking a trip back in time; I can relate.

Working in a tertiary center in the intermountain West, I am often taking care of patients transferred from small hospitals in Wyoming or Montana, and it seems it is the exception rather than the rule that imaging, for example, is sent with the patient. Usually there is a report of an image, but then, as a clinician, you have to decide if you want to take the word of another doctor whom you’ve never met from a place you’ve never been regarding a patient whose life might be in danger vs. reimaging. Depending on the urgency, the latter often happens, which leads to mounting costs for the medical system to absorb and increasing exposure to unnecessary radiation.

It seems that there are two main barriers to the melding of health care and modern-day technology that even the village children in Granada, Nicaragua, carry in their front pockets: the up-front costs of buying the technology, such as EMR technology, despite the likely long-term cost savings, and HIPAA. The first could be credited to Father Capitalism, the latter to Uncle Sam.

When I imagine my ideal admitting day, it would be something like my day at Yellowstone, without the snow and blue sky. I would take a call from OSH (outside hospital), and while talking to the provider I would be getting real-time images on my PC or phone. We could talk like old friends about the subtleties seen on the imaging and the way the T waves of the EKG flow on the red, checkered paper. We would bring in our colleagues from radiology and cardiology and come to a conclusion about the most likely diagnosis and the safest place for the patient.

Gone would be the nervous anticipation of a "transfer patient" whose clinical state may or may not be consistent with the report you just received and whose medical records sent may or may not just contain a stack of nursing notes without labs, imaging, or current med list. One step further in my clinical dreamland would be something akin to what happens at my dog’s veterinary office, a virtual technological paradise. A Star Trek scanner would be waved over a chip in the abdomen of my patient and instantly onto my iPhone would appear a med list, allergies to medicine, imaging, EKGs, and different files for each hospitalization, with a wonderful H and P and DC summary for each, available at my fingertips.

I understand that this will likely never happen; just the word chip would bring up images and fears of a government-run Orwellian society to many of my patients and probably most of my family; but every time I take a picture on my iPhone and share it instantly with people half a world away, I get a warm feeling in my belly that this may one day may be a reality. A boy can dream, can’t he?

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center in Salt Lake City in July and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.

Recently, I went snowshoeing with my wife and dog in West Yellowstone. The sky was so blue, the snow so white, and the scenery so perfect I had to take a picture and share it with my friends and family. No need for a fancy camera, I pulled out my cell phone, snapped a dozen photos, posted a handful on Facebook, and within seconds my friends from Mexico, Nicaragua, and Venezuela were sharing the moment with us and making comments.

Key words in the above paragraph are "sharing" and "within seconds." I was miles from a highway, hundreds and thousands of miles away from family and friends, and yet I was able to easily, instantly, share information with them.

© Aaron Amat/Fotolia.com

Another scenario: One month ago my wife was changing doctors. We arrived at her appointment and the faxed medical records had once again not "gone through." They had become lost – not scanned in, not received, not filed, or one of the many unwanted outcomes that seem to be the norm of the antiquity that is "faxing." Instead of again playing the fax game, I opted to drive across town, walk into the old clinic, pick up the medical records with my hand, and drive back to the new clinic; it took about an hour. That is how slow and unreliable I find the process of faxing.

In a profession where the communication of information and data is vital to providing care, and in an age where cost management is ever on the minds of administration, we are hamstrung by fax machines, pagers, and antiquated methods of communication from the early nineties. There was an article in The Atlantic recently about how walking into a doctor’s office was like taking a trip back in time; I can relate.

Working in a tertiary center in the intermountain West, I am often taking care of patients transferred from small hospitals in Wyoming or Montana, and it seems it is the exception rather than the rule that imaging, for example, is sent with the patient. Usually there is a report of an image, but then, as a clinician, you have to decide if you want to take the word of another doctor whom you’ve never met from a place you’ve never been regarding a patient whose life might be in danger vs. reimaging. Depending on the urgency, the latter often happens, which leads to mounting costs for the medical system to absorb and increasing exposure to unnecessary radiation.

It seems that there are two main barriers to the melding of health care and modern-day technology that even the village children in Granada, Nicaragua, carry in their front pockets: the up-front costs of buying the technology, such as EMR technology, despite the likely long-term cost savings, and HIPAA. The first could be credited to Father Capitalism, the latter to Uncle Sam.

When I imagine my ideal admitting day, it would be something like my day at Yellowstone, without the snow and blue sky. I would take a call from OSH (outside hospital), and while talking to the provider I would be getting real-time images on my PC or phone. We could talk like old friends about the subtleties seen on the imaging and the way the T waves of the EKG flow on the red, checkered paper. We would bring in our colleagues from radiology and cardiology and come to a conclusion about the most likely diagnosis and the safest place for the patient.

Gone would be the nervous anticipation of a "transfer patient" whose clinical state may or may not be consistent with the report you just received and whose medical records sent may or may not just contain a stack of nursing notes without labs, imaging, or current med list. One step further in my clinical dreamland would be something akin to what happens at my dog’s veterinary office, a virtual technological paradise. A Star Trek scanner would be waved over a chip in the abdomen of my patient and instantly onto my iPhone would appear a med list, allergies to medicine, imaging, EKGs, and different files for each hospitalization, with a wonderful H and P and DC summary for each, available at my fingertips.

I understand that this will likely never happen; just the word chip would bring up images and fears of a government-run Orwellian society to many of my patients and probably most of my family; but every time I take a picture on my iPhone and share it instantly with people half a world away, I get a warm feeling in my belly that this may one day may be a reality. A boy can dream, can’t he?

Dr. Horton completed his residency in internal medicine and pediatrics at the University of Utah and Primary Children’s Medical Center in Salt Lake City in July and joined the faculty there. He is sharing his new-career experiences with Hospitalist News.