My Back Itches

I love my job. I love the hospital environment. I love talking care of all different kinds of people. Different walks of life. Men. Women. Young. Old. Really old. Sometimes really, really old. Hips. Knees. Infection. Heart Failure. COPD. Pneumonia. DVT. PE. Stroke. Cellulitis. Asthma. Drug OD. Mental Illness. Back Pain. Headache. Diabetes. Heart Attacks. Anything that can inflict bodily harm or mental anguish on an adult is fair game for my skills. And I love it. I love interacting with other doctors. I love interacting with the nurses. The respiratory therapists. The unit clerks. The occasional administrator. I love being on the VTE committee. I love talking to the radiology techs. The security folks. The volunteers. The cleaning staff. I see it all. And I love it. And I get to go home at night without a pager and no interruptions.

We have a great set up. We are a private practice. We are a voluntary system. Hospital admitting privileges are available to all docs. We see patients at the request of the primary care doc. Occasionally we get called to see consults on patients we shouldn't have been called for. Most of this problem has been fixed by diligent awareness. Just yesterday I was consulted by a psychiatrist to see an academic physician's patient. But with any program you simply have to do your best to respect professional courtesy.

On a regular basis, sick patients happen. The ones that are trying to die on you or are trying to experience a major complication. There are days where page after page after page comes from one nurse with lots of bedside concern for a patient. Those are the times where running an office practice and a hospital service can really be frustrating (or so I've heard). I could never do both. And feel good about it. Unless of course, you are the primary care doc who sends medical management to that organ's specialist. What I like to call The Multi Specialty Patient.

The Pan Consult.

I have heard time and time again from the pulmonologists, the nephrologists and the gastroenterologists in my community how great their lives have become since hospitalists came to town. Routinely, they would be asked to evaluate and admit patients in the middle of the night for routine medical issues. Things most primary care docs could manage. For the specialist, their lively hood is determined by their ability to "kiss ass". To keep the gravy train alive. At least when there is competition for patients.

Doctors walk a fine line everyday. Docs are full of big fat egos. They think they are the best and often times, they get into silent pissing matches with each other about management and evaluation. Occasionally, as one of my partners related, these battle of the egos spill into the medical chart in the way of "Chart Wars." Writing abusive comments about practice style or flinging ego insults at others through the written record.

Specialists, especially in areas where many specialists saturate a market, must always be cognizant of their interaction with their bread and butter primary care docs. The indirect back scratching that goes on behind the scenes used to go like this:

A 3 am patient with a GI bleed is in the ER.

ER Doc: "Dr PCP, Mrs Smith, your 79 year old patient is in the ER with a GI bleed."

Primary Care Doc: "Call Dr Colon to see."

ER Doc: "Dr Colon, Dr PCP would like you to see Mrs Smith, a 79 year old with a GI bleed."

Dr Colon: "Has Dr PCP seen the patient?"

ER Doc: "No"

Dr Colon: "Thank you"

Phone hangs up.

Dr Colon: "SH$%, F*&K, B*@CH, B@^%$RD"

Now, in the old world, Dr Colon would role his ass out of bed at 3 am to see a 79 year old granny with a likely stable diverticular bleed. In return, Dr PCP would return the favor by sending Dr Colon his next 20 outpatient screening colonoscopies and endoscopies. I scratch your back, you scratch mine. In other words, primary care docs used the specialists because they could and the specialists allowed it because they had to. In a world of choice, those who live off the decisions of others must satisfy their gravy train. Most people don't call up a specialist so a large part of any specialty practice, medical or surgical, is based on the referral patterns of primary care docs in the community.

But hospitalist medicine has changed all that. The back scratching has left the building. When a primary care turns over care of their patient to me, decisions in patient management are made by me. I make the decision to consult a specialist or not. To order labs or x rays or biopsies. I make decisions on medications. Follow up studies. Follow up appointments. The primary care doc has placed their full faith and trust in the care of their patient on me. And I accept that responsibility.

Now, I will be the first doc in the world to say 'All docs are not created equal.' In a world of choice and a push for transparency, one has to ask themselves, how can you chose your hospitalist? Well, sometimes you can and sometimes you can't. Hospital based practices are difficult to shop around with.

Anesthesiologists

Radiologists

Trauma surgeons

Hospitalist

Emergency Doc

If you come to the hospital, you get whomever shows up to say "Hi". That's not choice. But then neither is the ambulance driver that picks you up. Neither is the fireman that shows up at your burning house. Neither is the state attorney who shows up to protect your rights. Neither is the police officer that shows up at your home invasion.

At some point in the management of the unexpected life event, which most hospitals stays are, one must accept a certain amount of trust and faith in the people that respond. That they have been screened by credentialing process. Sometimes this is difficult to accept. And I understand that. I look young. And many times without even a word, I can see the hesitation and concern in the eyes of the patient or family.

"Are you really a doctor?"

Generally, with the time I spend and my comforting bedside manner, most feel quite at ease with my abilities. Now. How many people will try and find my state license to verify I am a doctor? How many will try to find if I am board certified? How many will want to know my board scores? Well, I suppose only the really paranoid ones.

Regardless. In hospitalist medicine, a lot of the back scratching has left the building. Since I do shift work and don't carry an outpatient practice, who I consult has everything to do with the ability for mutual respect. With a few exceptions, the vast majority of the hundreds of thousands of doctors are well qualified to practice medicine in their scope of practice. So, for the most part (there are exceptions to all rules), which consultant I ask to assist me has more to do with how well they get along with others (and me), not how well they practice medicine.

And I am not ashamed to say that. Because if I, as captain of the ship, must care for a patient that needs an expert opinion, I need to be able to communicate with said expert. I don't need to be pissed on. I don't need to be crapped on. I don't need to be abused and yelled at.

You won't get any back scratching from me. If you treat me with respect. I can work with you. If you treat me like trash, I can't work with you. And by default, neither will my patient. That means whether my patient has insurance or doesn't is not my fault. What used to be back scratching is no longer. Because I take care of unassigned patients (= no insurance), a consult from me may be uninsured. There is no guarantee that if you see this uninsured morbidly obese patient with pancreatitis and choledocholithiasis and cholecystitis, there is no guarantee that I will refer the next 20 outpatient overnight BlueCross lap choles your way.

Hospitalist medicine has ended those types of relationships.

Is that good? Or bad?

Well, I can understand the frustration from the unsubsidized docs of this world. Their time is uncompensated. And it's not fair that they eat the cost. A sort of forced slavery. Working for free. Getting specialists to take call in the ER is becoming harder and harder to do.

The uninsured

The sicker

The ones without established physician relationships

They are all more likely to experience unsatisfactory results and more likely to sue. All the liability with no compensation. It is no wonder specialists and primary care doces alike are leaving hospital based practices, taking themselves off call, or demanding compensation for call. It is no wonder why giant holes in specialty coverage exist all across the country.

What that leaves me with are difficult situations. I must navigate the seas with new techniques.

There is no back scratching. No freebie now for the golden egg next month.

It is not my fault. When I get yelled at for "always consulting us on the uninsured", if you only knew how untrue that is. When I see patients who are uninsured, it is not my fault they got sick. It is not my fault they don't have insurance.

When a surgeon or specialist accepts responsibility for care of the difficult or uninsured cases, my respect and desire to work with them increases. When my respect increases, my desire to seek out your opinion increases. That means you can expect to hear from me when the patient has Blue Cross, United, Medicare, and yes, even the poor self pay sap who is probably experiencing some of the worst financial trauma we could only imagine.

And when you see my paying customers, that means the primary care doc is also seeing your fantastic work. And that will keep your gravy train alive and well.

Quite clearly, in a land of choice and competition among docs, the back scratching mentality is disappearing in favor of mutually respectful relationships. Good hospitalists force communication into a system that is notorious for passive aggressive behavior and passing the buck of responsibility. If I am going to talk to another doc, it's going to be one that communicates like an adult. I wouldn't talk to a 3 year old about septic shock with obstructive cholangitis any more than I would with a doctor acting like a child.

Hospitalist medicine has changed the landscape. New relationships are being formed. Based on respect instead of fear and ass kissing. Some will survive. Those that don't accommodate will die the way of the dinosaur. You could, in fact, say that these are market forces creating respect where none previously existed.

Comments on the grammar appreciated.