Comments on: That’s Convenient

By: NR

NR — Thu, 17 Jul 2008 04:10:30 +0000

how about “paying” residents per admission. then medicine residents would be elated to take an admission. any amount would help in residency ?

By: Dr. Dredd

Dr. Dredd — Wed, 16 Jul 2008 14:31:18 +0000

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.

By: Stalwart Hospitalist

Stalwart Hospitalist — Tue, 15 Jul 2008 21:41:41 +0000

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.

By: TK

TK — Mon, 14 Jul 2008 19:44:35 +0000

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?

By: The Happy Hospitalist

The Happy Hospitalist — Mon, 14 Jul 2008 18:25:12 +0000

The path of least resistance is the path most taken

By: DoctorJay

DoctorJay — Mon, 14 Jul 2008 14:48:58 +0000

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.

By: TK

TK — Mon, 14 Jul 2008 14:14:11 +0000

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.

By: Stalwart Hospitalist

Stalwart Hospitalist — Mon, 14 Jul 2008 13:57:31 +0000

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.