By Suzanne Berman, MD
Edwin Leap, MD, an emergency room physician, makes a touching plea to those of us in rural medicine: don’t abandon your inpatient practice and night call responsibilities.
He articulately describes white coat flight – the trend away from inpatient and ER call as many primary care physicians, and even some specialists, drop their hospital privileges in search of fewer hours, better patients, and better pay. But he doesn’t address my major ongoing apprehension about inpatient care: frustration with the hospital milieu.
I like working at my office. I can always park where I want to. It’s laid out how I like, with all my stuff clean, functional, and close at hand. And if something breaks, or someone builds a better ZXK Analyzer 2000, I can buy another one if I want. But the main reason I like working at my office is: I have a great staff team. Our nurses are cheerful, helpful, compassionate, and solid. I know this, because I’ve worked with some of them for nearly ten years. They know how I communicate, what worries me, what I do well, and what I need help with and when. Similarly, they’re great at serving our patients without constant micromanaging, because they ask for help when it’s not clear what to do. We’ve worked together so long, day in and day out, in sickness and in health, that we truly work well as a team.
Let’s contrast this empowered team with the inpatient experience of, oh, say, the same pediatrician at a smallish community hospital. Because we’re physically removed from what’s happening with our patient 23 hours of the day, we have a lot of catching up to do in the remaining hour at the hospital. And rather than an “hour of power,” it’s often marked with frustration:
Me: “Wow, this output log said Johnny hasn’t peed since yesterday afternoon. Has he really not urinated in over 16 hours?”
Nurse: “Ummm… hmm, I don’t know. Night shift didn’t tell me anything about his urine.”
Me: “That may be, but if he hasn’t peed in 12 hours, we might have a problem.”
Nurse: “Well, maybe he’s peed. His mom has been changing his diapers.”
Me: “Well, if she’s changing diapers, then he’s peed. So why didn’t night shift record his urine output like we asked?”
Nurse: “I don’t know. You’d have to ask night shift.”
Me: “Well, night shift isn’t here.”
Nurse: “I’ll ask if mom can at least remember how many diapers she’s changed.” [leaves, comes back] “Oops, mom went home to get a shower. Dad is here now. He doesn’t know anything about diapers. He hasn’t changed any in the past 5 minutes.”
Me: “OK, well, please page the nurse supervisor to get a hold of night shift. Because I’m really worried about this baby’s kidneys now.”
[ten minutes pass]
Nurse Supervisor arrives.
Nurse Supervisor: [after the above is relayed] “Oh, OK, I’ll find out.”
[twenty minutes pass. My hour is up. I need to be back at my office.]
Nurse Supervisor: “OK. I got a hold of night shift. She knows the baby peed but doesn’t remember how much.”
Me: “But why didn’t she write it down in the log?”
Nurse Supervisor: [shrugs] “Maybe it just didn’t seem that important. But we can discuss it next month at our inservice.”
Nurse: “How can you measure how much a baby pees, anyway? It’s not like the baby can pee in a urinal.”
Nurse Supervisor: “I hope you don’t expect us to straight cath babies!”
Me: [surprised] “You do diaper weights. Weigh the diaper dry, then put it on the baby. When it’s wet, weigh it again. The difference is pee.”
Nurse Supervisor: [frowning, peering at chart] “Doctor, you actually didn’t write an order for diaper weights. Just urine output.”
Nurse: [thinking through the previous instruction] “….But that would give you a weight in grams. Do you want us to record urine in grams?”
Me: “No! One gram is one milliliter of urine.”
Nurse Supervisor: “Also, the computer system doesn’t allow us to put in diaper weights.”
Nurse: “Oh, our scale is broken. We’d have to get a new one.”
Nurse Supervisor: [making note] “I can put in a Capital Expense Request Form. However, I heard they’re not approving new expenses until the 3rd quarter.”
Me: “I. Just. Need. To. Know. How. Much. This. Baby. Has. Peed.”
Nurse #2: [walking by] “Oh, I bet I know why that baby hasn’t peed. Night shift told me they turned the IV fluids down because the rate seemed like too much for the baby, who was peeing too much.”
The hospital setting lacks the efficiency, communication, chain of command, and ready materials that I’ve come to expect in my office.
Julia Child could prepare a souffle anywhere, certainly, but she might find it difficult in my kitchen, which contains only one old wire whisk, spotty lighting, and an oven with an irregular temperature control. If compelled to do so, she’d no doubt be asked by foodies why this souffle wasn’t up to her usual standards. “Oh, you see,” she’d say cheerfully in her New England warble, “we’ve been camping in the country!”
But unlike Julia, I’m held to a high standard of care whether I’m at my office or some other place. It’s fundamentally easier to deliver good care when I’m in a familiar environment, surrounded by people and equipment I trust, than when my critical information is delivered (or not) by people unfamiliar to me (who was the mysterious nurse called “Night Shift,” anyway?). White coat flight isn’t an isolated phenomenon. Many hospitals struggle with “pink scrub flight,” or the mass exodus of well-trained nurses from front-line care to higher-paying administrative jobs with better hours and less stress. The crusty nursery nurse who’s been there since I was a nursery patient, whom I know and trust to spot a sick baby at 100 paces, has been replaced by a rotation of a half-dozen part-time nurses whose training and experience are primarily in adult medicine, and whose names I’m still struggling to remember. If I feel a nurse made an inappropriate or unsafe call, I can report it, but I’m not part of her training or mentoring process; that’s “an internal hospital matter.”
If Julia knows she’s going to be working in a less-than-well-equipped kitchen, she’ll be sure to bring her own $59 zester. But hospital work requires, with few exceptions, use of hospital staff and hospital equipment, for legal reasons. And on a witness stand, when asked to explain a child’s bad outcome, I can’t wittily demur about the less-than-optimal hospital setting; I’ll have to say that I did my best given the shortcomings of our local community hospital, a damning statement in the eyes of trial lawyers.
Dr. Leap is an experienced emergency room physician. I would imagine that his hospital emergency departments are well-managed such that he has a similar experience to me working in my office. After signing in, he’ll work an eight-to-twelve hour shift with the same nurses, therapists, and techs he’s worked closely with for the past three to fifteen years. New faces get assimilated into an experienced team quickly, because he’s working side-by-side with them, watching their performance. He knows Lab Tech David is the best “sticker” on old-lady-veins this side of Interstate 55, so that’s who he taps to draw the blood on elderly Mrs. Jones. Registered Nurse Mendoza is compassionate, gentle, and bilingual, so she’ll work with the Latina woman coming in for a sexual assault evaluation. Registered Nurse Miller is new and not very experienced with chest pain patients, so letting her monitor heart rhythms isn’t a good thing for her to solo yet. However, he’ll have an opportunity to mentor her today as they work closely together treating Mr. Aziz, who’s come in with chest pain. Dr. Leap sees quickly what’s going well and what’s not – because he’s on site with his team, forming rapid assessments of the team’s skills and performance. He can train or mentor new or inexperienced staff in the hands-on way most of us learn best. Most importantly, he can intervene if things aren’t going well for his crew.
Money and hours are certainly paramount considerations in the decision of physicians to pursue or abandon inpatient responsibilities. However, for the pediatrician who wants to treat her patients in the local hospital, we need to make the rest of the hospital as responsive to community physician leadership and ideas as Dr. Leap finds his emergency department.
Suzanne Berman is a general pediatrician in private practice in Crossville, Tennessee. Her family works, lives, goes to school, worships, and buys stuff from Walmart all within the 38555 zip code.