I hate it when we run out of beds in the hospital - who doesn’t? I especially hate it when we run out of psych beds. These patient will tend to linger down in the ED for days - occasionally not bothering anyone but often causing trouble. Refusing to stay in their room, wandering around, demanding to go smoke, pestering the staff. They are CLEARLY not well served in the ED. Anyway, the other day we ran out of female psych beds and I was groaning. The psychiatrist said to me “is there anyway we can find a reason to admit her to medicine?” “I don’t know” I said, “she is really just depressed and addicted to narcotics. Well, miracle of miracles, about 10 minutes later she started vomiting and passed out after hyperventilating. BINGO! Medical Admission! Hurrah! Also, lucky she has an internist who was fine with the admission. It’s the little things that make a long shift go by faster…..
Canadian Pharmacy
This has been happening more and more with the advent of duty hour limitations for residents, especially in the surgical disciplines…Medicine seems to be the admission service, with everyone else happy to revert to consultative status, even if the primary problem is surgical, or psychiatric, etc.
I will fault my Emergency Department colleagues to some degree as well, since they often will call the appropriate service first, but allow a junior resident (or intern!) on the service to “recommend” admission to medicine so that they can follow as a consult. By the time my team or I get the call, every other service has already refused to admit the patient.
It’s not that I don’t love doing H&Ps and discharge summaries (and, as a hospitalist, I’d wager that I manage transitions of care better than any other service), but sometimes this is just ridiculous.
I agree completely. I get infuriated when a totally stable elderly patient with a hip fracture gets forced onto medicine because an orthopod is “not comfortable” with them being on his service. I think he means, “I am not comfortable with getting phone calls at night from the nurses” I had this guy once say to me “She’s 75, BY DEFINITION she should be admitted to medicine!” I usually try to let the medicine people fight directly with the other services instead of getting stuck in the middle and having both pissed off at me.
The more things change, the more things remain the same! Back in ancient times (the early 80’s), my fellow residents and I designated the Medicine Service as the Common Dumping Ground. Our slogan was “Give us your tired, your poor, your (unmentionable) ..” and our motto was “Sh*t slides downhill.” The nature of being a generalist is that you are responsible for all stuff that doesn’t come under the purview of a specialist (i.e., they can’t get paid for doing a procedure for). Not going to change any time soon.
The path of least resistance is the path most taken
Seriously HH. Pertaining to that case I just mentioned, I asked the hospitalist the next day (the residents swallowed the admission during the night) if she was upset about the hip fx on her service - and even offered to support some sort of policy whereby subspecialists cannot just routinely dump patients on to medicine. (not to mention to say something to the orthopod about the dump) She just shrugged her shoulders and was like “oh well” that’s the way it is. Our hospital is trying to build a hospitalist service and I wonder if she needed to keep the numbers up?
I, too, have witnessed TK’s described phenomenon of the “uncomfortable” orthopedic surgeon. I take this sometimes to mean, “You’ll take better care of her medical issues as the primary service.” (Probably true in most cases.) It sometimes means, “she’s old and I’ll probably hurt or kill her if I’m in charge.” (Probably not true in most cases, but infection, pressure ulcers, VTEs and delirium are real issues to watch out for.) And, sometimes, unfortunately, it obviously means, “I’m a surgeon. I don’t like documentation and worrying about discharge paperwork.” These physicians, while not common, are not physicians. They’re technicians, nothing more.
When I was a resident, it always infuriated me when the surgeons would say, “We’re in the OR all the time. We can’t be bothered by calls from the floor, so this patient should be on the medicine service.” It implied that our time was somehow less important than theirs. We had a very good medicine consult service, and I always thought we should use it more. I wonder how much of this was internal politics (e.g. “My Chief can beat up your Chief…”)
When I finished residency, I resolved to do only outpatient medicine. This was one reason why.
how about “paying” residents per admission. then medicine residents would be elated to take an admission. any amount would help in residency ?