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Coat Tales


Russ Cucina, MD, MS, a hospitalist at the University of California San Francisco (UCSF) Medical Center, and a colleague once spent a week wearing pedometers on the job to study how much ground they covered in the course of managing their patient caseloads in a huge hospital like UCSF. The result: an average of four miles walked per day.

“The usual productivity infrastructure for physicians in their offices is simply not as available to hospitalists, or isn’t under our control,” Dr. Cucina says. There may be networked computer terminals throughout the hospital, but how many there are, how accessible they are, and how much competition there is for them varies. Hospitalists may have their own offices, desks or shared office space, depending on institutional commitments, but these may be a trek from patient care areas.

As a result, they must bring essential tools of their trade on their persons. Some carry a briefcase or wear a fanny pack, but more often these essential tools are stuffed into every available pocket of their medical lab coats.

Dr. Cucina’s short list of essentials is typical of working hospitalists. It includes his “smart phone,” combining a personal digital assistant (PDA) and cell phone, pens, a reflex hammer, a tuning fork for testing neurologic sensitivities, a stethoscope, swabs for sterilizing the stethoscope, a stash of large hospital gloves (which can be a hard size to find), and a bulky and awkward—but secure—prescription pad in a cardstock wrapper.

He also totes a stack of 3-by-5-inch index cards held together with a steel ring—one card for each active patient, updated daily by hand with medication changes, lab results and other information provided by the residents. “I have tried higher-tech approaches,” he explains. “I am the hospital’s associate medical director for information technology, and I need to keep up to date and try new things, including the various applications for keeping patient lists on line. But nothing has yet beaten out hand-written index cards for efficiency and ease of use. The time it takes to input this information electronically just isn’t worth it.”

Hospitalists say additional medical tools, such as an otoscope or ophthalmoscope, could be helpful but may pile on too much bulk and weight. “I’m often challenged to find one on the floor when I really need it,” Dr. Cucina says. Portable scopes are also quite valuable and at some risk for disappearing from an unattended lab coat in the highly trafficked hospital setting.

Russ Cucina, MD, a hospitalist at UCSF, displays his PDA, an essential tool in his work. He also carries a reflex hammer, a tuning fork for testing neurologic sensitivities, a stash of large hospital gloves, a prescription pad, and a stack of 3-by-5 index cards—one for each active patient.

PDA Is No Panacea

For many hospitalists, one key to efficient mobility on the job is the PDA or laptop computer, with basic references such as UpToDate, Epocrates, Tarascon Pocket Pharmacopoeia, or the Washington Manual of Medical Therapeutics, either loaded or accessed via the Internet. PDAs involve serious compromises balancing size and weight with ease of keyboard use, ease of reading the screen, and memory or processing speed. (See “Tackle Technology,” November 2007, p. 22 for a discussion of how hospitalists use portable computing devices on the job.)

“We’ve come a long way from tongue depressors and otoscopes,” says William Ford, MD, program medical director for Cogent Healthcare’s large and expanding hospitalist group based at Temple University, Collegeville, Pa. “Some of us at Temple, depending on the service, carry one or more cell phones and between one and three pagers, in a pocket or attached to a belt.” The doctors may have their own PDAs, but Cogent no longer supplies them, having converted to a Web-based tool that offers a variety of practice management resources accessed by laptop computers via the Internet.

Dr. Cucina believes the technology is evolving toward a tablet device that will integrate more of the resource databases hospitalists need in their daily practice with other essential functions, such as lab results, billing, and communications with primary physicians—all in a user-friendly scale and format. In the meantime, there’s still a lot that has to be stuffed into pockets.

Some hospitalists also prefer to hold favorite reference resources, such as the pocket-sized Sanford Guide to Anti­microbial Therapy in their hands. That also involves tradeoffs, notes Michelle Pezzani, MD, hospitalist at El Camino Hospital in Mountain View, Calif.

Have Office, Will Travel

For Duane Spaulding, MD, FACP, president and executive contracting officer for Advantage Inpatient Medical Specialists, practicing at Penrose St. Francis Hospital in Colorado Springs, Colo., some of the “more interesting” things he routinely carries from floor to floor as a working hospitalist include the following items:

  • Small folding leather case containing fresh business cards for patients and families;
  • Yellow, 3-by-4-inch Post-It note pad with name embossed at the top to leave queries in the progress notes section of the chart for a consultant to review and respond to. He leaves “messages that are important but do not warrant an interrupting phone call and should not be part of the official/permanent medical record”;
  • High-quality Welch-Allyn penlight for full visualization of eyes, teeth, throat, skin lesions;
  • PDA securely in a pouch on his belt (he has “been doing so since 1998 and have never dropped it”). He uses it for quick medical reference, drug interaction programs, and consultants’ phone numbers;
  • Tiny stapler (“nothing is more frustrating than wasting time looking around each nurses’ station for this essential item”). He uses it to keep discharge forms from becoming separated;
  • Tiny single-hole puncher so prescriptions can be clipped into the chart;
  • Alter-proof prescription pad embossed with his name;
  • Rubberized “finger cot” for “my non-dominant hand’s thumb—allows my otherwise slippery fingers to whip through an old chart at a near-blurring pace looking for key information I need ASAP”; and
  • Small self-inking rubber stamper with his name and office phone number “to unquestionably identify my signature [not as a replacement for the signatures, which is illegal] on all progress notes and orders we sign.”—LB

“I tried carrying a book bag over my shoulder, but I felt like a school kid,” Dr. Pezzani relates. “I also noticed that the more reference books I had stuffed into my pockets, the less confidence other people seemed to have in me as a physician.” Not to mention that her pockets ripped open from the weight. She even developed a sore neck from her ergonomically unbalanced, overstuffed lab coat.

“Although I love being a hospitalist, it’s getting to the point where I feel disorganized because I have no real home base,” Dr. Pezzani laments. She finds her hospitalist group’s shared office—a converted labor-and-delivery room with no windows and three desktop computers for nine doctors—less than ideal. She spends as little time as possible there.

“My life would be easier if I didn’t have to carry my office in my pockets—my ink-stained pockets,” she says. “I can’t carry my laptop around with me because of the neck pain, so I asked the hospital to give me a locker closer to the middle of the building. It has also become a kind of science for me to transfer a few personal essentials into a little satchel with a string that I wear around my neck,” since a purse is not feasible.

Love/Hate Situation

Dr. Cucina uses an online custom supplier of medical lab coats with extra, zippered pockets on the inside and outside. He’s careful not to let the lab coat of out his sight when he takes it off.

Randy Ferrance, MD, a hospitalist in internal medicine and pediatrics at Riverside Tappahannock Hospital in Tappahannock, Va., acknowledges his own love-hate relationship with the lab coat. In his pockets, he carries a stack of 3-by-5-inch index cards, an 8.5-by-11-inch hospital census sheet, folded over, a prescription pad, a highlighter pen and spare pens, the ubiquitous stethoscope, an EKG caliper, a reflex hammer with microfilament test for diabetes, and a pocket Sanford Guide.

“I’d love to ditch the lab coat,” Dr. Ferrance says. “I often take it off when I sit down and sometimes end up leaving it behind, such as in the medical dictation area. I never want to wear one when I’m talking to a child. But for a lot of families of patients who are critically ill, it is a symbol, almost like the armor of the knighthood of medicine. You have to read each family, but for some, you lose credibility when you take it off. They’re looking for everything that medicine can offer, and the lab coat gives them more confidence in you.”

Dr. Ferrance appreciates the smaller size of his 47-bed hospital, where he is never a long walk from anyplace. He frequently returns during the day to his office, which he doesn’t have to share with other doctors. He uses it for family conferences and to store larger manuals, his laptop, and diagnostic kits.

He also values his Treo Smart phone, which incorporates a variety of programs, including a drug reference, billing program, lab reports on active patients, pediatric growth chart program, pneumonia severity index calculator, a medical calculator, Geriatrics At Your Fingertips, the Harriet Lane Handbook: A Manual for Pediatric House Officers, the American Association of Pediatrics’ Redbook comprehensive online infectious disease resource, hospice eligibility criteria, a camera—“to take pictures of odd lesions”—and access to e-mail and sports scores.

Although a briefcase is one more thing to lug around and risk losing, Julia Wright, MD, director of hospital medicine at the University of Wisconsin Hospital in Madison, says she carries a bag that is a woman’s version of a briefcase, with her laptop and active administrative files required for her growing administrative duties as director of an academic hospitalist group.

“There are advantages to being mobile, but disadvantages as well,” Dr. Wright says. “You just can’t get everything done. I get between 50 and 60 phone pages a day, and a lot of curbside consults, as well.” The medical center is restructuring teaching services so a hospitalist’s assigned patients would be more often concentrated in one area, with less running from floor to floor, as well as exploring new office facilities for the hospitalist group.

Currently, 11 University of Wis­consin hospitalists share a room with five cubicles. “I’ve put my pictures up on the wall anyway, and I keep my files, stapler, and office supplies there. A couple of my partners keep their reference books there. What I like about sharing space like this is it can help with communication and collegiality within the group. We do a lot of patient hand-offs there. But as we grow and it becomes more crowded, we’re going to need some more dedicated space.” TH

Larry Beresford is a medical writer based in California.

The Hurdles of Mobility

The mobility required of the working hospitalist can be a big hurdle to overcome, suggests David Grace, MD, area medical officer for the Schumacher Group’s Hospital Medicine Division and a hospitalist at Southwest Medical Center in Lafayette, La.

“I don’t like to carry anything in my pocket but keys, pager, cell phone, and patient list,” Dr. Grace says. “But I also need to carry a stethoscope, a penlight, a few pens, which are always getting lost, and a few laminated emergency reference cards, such as advanced cardiac life support protocols. I’m a firm believer that anytime I run a code, I need to stand there and go right down the checklist.”

The mobility challenge, Dr. Grace says, reflects the lack of standardization of protocols, forms or prescription order entry in the hospitals where he works. “So you still need paper progress notes and order sets. If you are mobile, the stack gets bigger and bigger. Unlike emergency physicians, who have access to stacks of paper, we carry these things in our pockets.” Dr. Grace wonders if there is a way to improve the capacity of doctors’ lab coats. “I’m looking for one with more than two outside pockets, but I don’t want to walk around in something that looks like a fly-fishing vest.”

He carries a Blackberry, which combines the functions of two previous PDAs, a cell phone and pager, although there are limits to what he can do on its small screen. A networked laptop would lack the battery life to get him through the day, with variable Web access at the hospitals where he works. At one facility there is only one Web-based computer terminal per floor for physicians to use. “Not long ago, I saw a patient with a very unusual condition, which only six people on earth have, and I found to be invaluable.”

Sometimes hospitalists work without any office space at all, Dr. Grace notes. “We have a small office here in the radiology department, next to the emergency department. The hospitalists share desks, which are small but workable. Years ago, when I worked in Phoenix, we didn’t have any designated workroom. You parked your car in the hospital parking lot, walked in the door, and you were on your own. Even now, if I need to make a private phone call, it’s hard. Sometimes I go out to my car to make sensitive calls.”

Another problem he notes is that the patients can be mobile, too, moving from the operating room to dialysis or X-ray. “Just finding your patient can be a challenge sometimes. ‘Oh, Dr. Grace, you just missed him, he’s in X-ray.’ I can ask the nurse to call me when the patient gets back to the floor. But they get tied up, and by the time they call, the patient’s gone again. Sometimes, the only place I can see the patient is in X-ray.”—LB

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