How A Hospitalist Physician Thinks: I'm So Busy

What is a hospitalist?  How does a hospitalist physician think and why are they so busy?

When ever I hear about "quality care",  I have to laugh.  I have to laugh because 99% of what I do on a daily basis is make judgment calls.  Decisions that I make based on the big picture.  Based on objective and subjective data.  Based on social and economic decisions.  When I hear about quality being defined as getting your aspirin, or getting your pneumovax shot, or getting your angiotensin converting enzyme inhibitor in left ventricular systolic function,  I have to laugh.  That's how the government defines quality.  That's how the government black balls you into "quality".  And since the Medicare National Bank  (MNB) controls the money,  they have become, the default expert opinion on quality clinical care.  Unfortunately, if they believe their quality indicators are a measure of quality patient care, or will have a significant impact on cost control,  I think they will be sadly disappointed on both fronts.   Let me walk you through several  real life examples of "quality care" in the real world.  At every branch in the thought process, clinical decisions must be made.   With no Cliff's Notes for us docs to cheat off of.  This following case is a common encounter for us internal medicine docs.  Very common.

An 82 year old nursing home patient has asthma dyspnea presenting as shortness of breath.

Let's stop right here.  Shortness of breath.  What does that mean?  Is that the patient's description?  Is that the care giver's description?  Can the patient talk?  Are they demented?  What is their mental status? We must first establish that the patient has a complaint.  A symptom per say.  Shortness of breath.  Where do we go from here?   As care giver,  what shall I do to provide "quality care"

Clinical Decision number one:  What should the caregiver do.  Check vitals?  Call the doctor?  Call the family?  Ignore it?  Check code status?  Talk to the patient?  What does the patient want?  Do they look labored?  Do they have a fever?  Are they acting funny?  Have they recently fallen?  What kind of medical problems do they have?  What medications are they one?  Are they having any other symptoms.  What is their functional status?  The decision tree starts at the nursing home.  It's not as simple as just sending the patient to the ER, although, that's what it has often become as the legal ramifications of natural death are not allowed anymore. In this case, the default,  go to the emergency room is declared, otherwise known as the path of least resistance.

Quality:  Is this the right decision?  Is this quality?  Where is the MNB's quality guideline for transferring a patient to the emergency room.  Is this the right decision?  A $500 ambulance ride and an hour of nurses time in paper work and transport.  Help me MNB.  Help me provide the right care at the right time, every time.

Patient arrives in the ER. Stop right there.  What should the ER doc do?

Clinical Decision number two.    In typical ER fashion, a standard of care across every ER in this country, the patient gets a cursory exam by the physician, a full past medical, family, social history by someone entering stuff in the EMR,  an "unobtainable" review of systems due to delirium, a CBC, BMP, cardiac enzyme panel, EKG, CXR, BNP, ABG,  UA PT INR testing and vital signs.  If the patient is confused, they get a head CT.

 Quality:  Is this the right decision?  Is this quality?  Where is the MNB's quality guideline for the evaluation of shortness of breath in an 82 year old demented  nursing home patient.  Thousands of dollars spent by the ER doc with no guidelines for providing quality care from the MNB.  Help me MNB.  Help me provide the right care at the right time, every time.

The data returns slowly over the next hour.

BP 169/88 HR 105 Temp 99.2 RR "20"  Wt 155 kg

HgB  8.2

MCV 72

WBC 19.2

Plt 122

Na 147

K+ 3.1

HCO3 30

BUN98

Cr2.9

pCO2 60

pH 7.32

pO2 62 on RA

CPK 640

MB  22

Trop I .29

BNP 250

UA with trace leukocyte, 1+ bacteria, 2-5 WBC's

INR 3.6

EKG Afib with nonspecific ST and T wave changes in multiple leads

CXR with mild central vascular congestion, no venous embolism, bibasilar atelectasis vs infiltrates,  poor penetration,  unable to hold breath.  Non calcified 4 mm nodule left middle lung

Head CT,  chronic ischemic gliosis with moderate atrophy.  No acute process.

Clinical Decision Number 3:  Call the primary care doc to admit and when they yell at you for calling them at 2 am, call the hospitalist.  This is too much abnormal data for even the best multitasking ER docs to handle.  They have 12 other patients to sort out.  But before calling the hospitalist,  give the patient labetolol for blood pressure, lasix if they're wet, fluid if they're dry, and Levaquin because every old person in the ER at 2 am needs it, and you don't want to miss the 4 hour window for "quality" care.  That's a given.

Quality:  Is calling the hospitalist the right decision?  Is this quality?  Where is the MNB's quality guideline for determining whether an 82 year old nursing home patient needs to be admitted.  Help me MNB.  Help me provide the right care at the right time, every time.

Clinical Decision Number 4:  Hospitalist evaluates the data.  To know where I'm going,  I have to know where I'm coming from.  What are my normal values.  What are my normal values to my demented 82 year old nursing home patient.  Here is a sampling of the differential diagnosis that goes on when presented with this kind of mountain of data:

From a surgeon:  I don't know, why is the patient still alive?  Call the hospitalist

From the ER doc:  I don't know,  they're sick.  Call the hospitalist

From the family practice doc:  I don't know:  Call the cardiologist, hematologist, ID, pulmonologist.  I'm too busy in my clinic to bother with this.

From any doc at 2am.  I don't know, call the hospitalist

From the hospitalist.  Dang,  did you see the nongap metabolic acidosis with a gap acidosis, and a stealth respiratory alkylosis from the aspirin over dose.  That was cool.

So what goes through a hospitalists mind when presented with this data?

Vital signs.  Stable or unstable.  Acute or chronic.  Any acute needs?  What's the general condition of the patient?

HgB 8.2.  The hemoglobin.  Acute or chronic?  Get old data, the baseline.  If acute, why?  Blood loss?  Where.  Colon?  Stomach?  Retroperitoneal bleed?  Uterine?  Urine?  Hemolysis?  What's the bilirubin.  What's the haptoglobin?  Any history of hemolysis before?  Any artificial valves?  TTP?  What's the platelet count?  Should I transfuse? Am I safe at 8 or shall I wait until 7.  Do I need lasix between units of blood?  If it's chronic what's the baseline.  Is it from renal failure?  Is it from primary bone marrow failure?  Multiple myeloma?  Myelodysplastic syndrome? Iron deficient?  B12 deficient?  Colon cancer?

MCV 72.  Red flag for chronic iron deficiency.  Doubt diet related.  Doubt malabsorption.  Most likely chronic blood loss anemia.  Is it colon cancer?  Hemorrhoids?  Polyp?  Bladder tumor?  Is it fibroids or a more ominous uterine carcinoma.  At 82 years old,  how aggressive should I be.  Should I ignore it?  Should I recommend evaluation?  Should I consult GI for endoscopy?  Should I do a pelvic ultrasound?  Should I check reticulocyte counts and iron studies and epo levels?

WBC 19.2  Elevated infection fighting count.  What's the differential on the smear.  Are there bands?  Are there atypical lymphocytes or other precursors.  What is her normal white count.  Is there a history of leukemia?  Is there fever?  Is she on steroids?  Is there an obvious source of infection?  Is her vitals OK?  Should I start empiric antibiotics?  Should I just wait?  Should I draw blood cultures?  Is there an abscess I'm missing somewhere?  Is there a subclinical pneumonia?  If I don't start antibiotics, will the patient get worse or do I risk creating resistance.  And which antibiotic should I start.

Plt 122.  Platelet count.  Low, but not terrible.  Why is it low?  Is she septic?  Is she an alcoholic?  Do I need to order liver tests?  Is her albumin low.  Does she have a history of drinking or of cirrhosis?  Was she on lovenox recently?  Could she have HIT syndrome?  Is it primary bone marrow failure?  What are her other counts?  Is she on a drug that can cause thrombocytopenia?  Should I ignore it, or just follow it through time?

Na 147.  Sodium is high.  Indicates some dehydration.  She needs fluid.  But how much?  And how fast?  And what kind?  Is it really that bad?  Can I just follow it?  If she is dehydrated, why?  Is she in lasix?  Is she not drinking?  Is the nursing home not feeding her?  Is she having problems swallowing?

K  3.1.  Potassium is low.  Just replace it.  Tell nurses not to call you unless it is 2.9 or less.  I've never seen anyone die from low potassium.  But it is probably to most common phone call in hospitalist medicine.  That and low urine output in a 90 year olds.

HCO3 30.  Bicarb is high.  Is this primary respiratory acidosis with compensation?  Is this primary metabolic due to diuretics?  What is her pH.  What is her kidney function?  Does she need fluids?  What kind?...

BUN  98.  Uremia.  Is this why she is confused?  Is she dried out from diuretics?  What is her baseline level?  Has it changed recently?  Does she have a pericardial rub?  How about uremic encephalopathy?  Is she on ACE?  Is she taking other nephrotoxic drugs?  Is she on meds that need levels checked?  Shall I give her fluid?  what kind?  How much?

Cr 2.9.  Kidney failure.  What is her baseline?  Acute or chronic?  Prerenal?  Renal?  Obstructive?  Any recent med changes?  NSAIDS, ACE inhibitors?  Any hypotension causes?  ATN?  What is her urine output?  Is there an infection?  What is her potassium?  Her bicarb?  Any urine eosinophils.  Any autoimmune disease?  Lupus?  Do I need compliment levels?  A CPK level?  A uric acid level?  Is she diabetic?  Hypertension?  Polycystic kidney disease?  Do I have an old ultrasound of her kidneys?  Do I need to get one?  Should I give fluid?  Is she dry or wet?  Will she go into pulmonary edema?  Is she DNR?  Are her legs swollen?  Does she have renal artery stenosis?

ABG.  Indicates chronic hypercapnic respiratory failure and hypoxemia.  Why?  Super morbid obesity?  Sleep Apnea?  Is she on CPAP?  Is she compliant?  COPD?  CHF?  Is she in heart failure now?  Right sided?  Left sided?  Both?  What is her EF?  What are her pulmonary pressures?  Does she have valvular heart disease?    Does she wear oxygen at home?   Is she on it now?  What is her code status?  Does she need Bipap now?  What settings?  Is she wheezing?  Does she need steroids?  How much?  Does she need antibiotics?  Which one (s),  Does she need nebs?  Which ones and what doses?  Does she need a pulmonologist?  Can she follow commands with inhalers or do I need nebs?  Do I need PFT's?  Do I need a CT of the chest to evaluate the nodule?  She's 82,  will it change anything?  What if it's cancer?  What if it doesn't matter that it's cancer.  Would she want something done?  Would the POA want something done?  How do I get a hold of the POA at this hour?  Who is the POA?  Does she need oxygen?  How much?  Is she in early heart failure?  What is her ejection fraction.  What is her BNP.

Cardiac Enzymes.  All of them are high, but out of proportion.  Is this really a heart attack.  Is it rhabdo.  If it's rhabdo, why?  Immobility?  Falling?  Thyroid disease?  Statin therapy?  What meds is she on.  Has she had an embolic event in an extremity.  Does she have pain   Is it a hematoma in her muscle I'm missing?  How about a retroperitoneal bleed?  Is it getting better or worse?  What is the trend?  Does she have a history of heart disease?  Any prior heart cath?  Any angina?  Should I give her aspirin and beta blockers now?  Should I repeat her echo?  Does she need a stress test?  Does she need any evaluation?  Does she need ACE inhibitors for LV dysfunction?  Should I just ignore it?  Should I put her on full dose lovenox, renal dosed?  How about amiodarone for her afib.

BNP.  250.  No man's land.  Ignore it.  Move on to more pressing things.

UA.  Slightly abnormal.  This is a normal finding for a nursing home patient.  Since they got their Levaquin in the ER, they will be fine.  The Levaquin will make her more confused, but that's ok.  We'll just tie her down to keep her from falling and experiencing a never event.

INR 3.6  It's high, but not terrible.  It's always high.  The Levaquin will make it go higher.  Do I need to hold it?  Change the dose?  Was the dose recently changed?  What is she on it for?  Is the afib chronic?  Is she bleeding from somewhere?  Has her diet changed?  Should an 82 year old nursing home patient even be on it?  What is her risk of bleed with it vs stroke without it?  Is she actively bleeding with a hgb of 8.2?    Do I need daily INR's?  What other drug interactions exist?

EKG.  Abnormal.  Most are.  What do I do with it?  She's 82.  Just follow it.  Do I need an Echo?  Is it different from an old one?  Where can I get an old one?  Even if it has changed, will I do anything with it?  Do I care?

CXR.  Hard to read.  They always are.  Morbidly obese.  Can't hold her breath.  Rotated.  Just give her the Levaquin to satisfy the MNB rules.  Her INR will go up.  She will get more confused.  Oh well.   As long as there is no big infiltrate or pulmonary edema, you play these by ear.  It could be the COPD/CHF/Pneumonia triad admitting diagnosis.

Quality:   Is this quality?  Where is the MNB's quality guideline for the evaluation of each and every abnormal laboratory.  Where is the MNB's quality guidelines for helping me to provide the right care at the right time, every time.  I see the patient got her aspirin and her antibiotic.  That's quality care.  Right?  What about the other 99% of the clinical decision making.  The enormous time spent making sure my patient got their aspirin is a pittance in time and money spent on patient care, when you look at the big picture.

I have given you just the initial peek at all the possible diagnostic trees and evaluation decisions that go on in patient care. And none of this even includes my necessity to document correctly and code correctly.   And I have to do all this in about an hour.   And I haven't even left the emergency room yet.  This is chronic illness.  If you think operating on a knee requires a vastly superior knowledge base, and therefore a vastly superior payment rate (about  5 times higher in  RVU terms )  I would argue just the opposite.  That multiple chronic medical conditions require an intense amount of thought and planning to determine the correct approach for each individual patient's needs.  And it takes time.  Lots of it.  The current system does not support that. The system supports fragmentation and compartmentalization and volume.

And that's why I'm so busy.