The world of medicine is like a bubble. A lot of people THINK they know what goes on there, but unless you're down in the trenches it's unlikely you do. So here is my semi-anonymous blog, here to tell you what really goes on in the life of a medical resident.

Friday, February 22, 2008

Adventures of a Hospitalist

Before I went on maternity leave, I was moonlighting (I moonlit?) at a community hospital. It's about an hour from the centre where I'm doing my emergency medicine training, and they had originally approached me about doing shifts in the emergency room. Just before I finished my family medicine training they arranged for me to work a buddy shift with the head of their emergency department (who also happens to be the head of the ED where I'm doing my residency) to test the waters. This community is clearly recruiting hard-core. I jumped at the opportunity. Like most community ED's, 99% of the stuff I saw during that 24 hour shift was routine. Belly pain, URTI's, broken bones, lacerations... nothing that made my heart race. 

It was the other 1% that made me reconsider. Without delving into details that might compromise confidentiality, a pediatric trauma came in. A pre-teen with a traumatic head injury who was awake and alert but confused and combative. He didn't end up intubated, but was eventually transferred by air to the closest centre with a pediatric neurosurgeon (none of the adult neurosurgeons were comfortable taking the case). It scared the crap out of me, and still would if I faced the same patient today.

So I decided not to moonlight in the ED while I was completing my residency training. Certainly not before I had completed my PALS and ATLS (both of which I'm scheduled to take over the next couple of months). The decision was not made lightly-- they were offering me $3K a shift (and now have upped the ante to $4K a shift). Money I could REALLY use right now. It's hard to say no.

But the hospitalist position was a perfect compromise. The hospital was desperate for coverage, and were hoping to lure me into signing with them when my training was done. The deal was sweet-- a spot on their Family Health Team, shifts in the ED, inpatient care (in the GP-run hospital), and some work in the nursing home attached to the hospital-- all of this for $500K a year. So doing the hospitalist gig occasionally would let me get familiar with the hospital and it's staff, and help me decide if I should commit to them or not.

Instead, I learned a lesson... nurses can make or break an entire hospital. 

Working in academic centres has been a mixed blessing when it comes to relationships with nurses. They are used to working with residents (and therefore having an MD in house all the time) and therefore may end up calling the resident for relatively minor issues simply because they're there and available. There are some truly phenomenal nurses that I've worked with that have probably forgotten more medicine than I know. And although I came across the odd bad apple, it seemed that in an academic environment the damage a lazy or incompetent nurse could do was mitigated by the fact that they often worked with other (better) nurses who could advise them and pick up the slack. I've complained about the occasional nurse in this blog before, but raved about good nurses far more than I've complained about them. And now I realize that I've been spoiled. 

Among the issues I've seen/experienced in my time at this hospital:
  • Orders for tests being disregarded. Seriously. If I ordered a test, it's because I think it's needed. If you disagree, tell me. Or the doctor on call. But to simply not carry out the order? You have to be kidding me.
  • Along the same lines-- if I am requesting accurate ins and outs on a patient with heart failure, DO THEM. Simply writing 'to bathroom' on the fluid output sheet isn't enough. I'm not asking you to cath them, just ask them to pee in the freaking hat. 
  • Please don't come to me in a panic because your patient doesn't have breath sounds on the right. Not when it is CLEARLY documented in both the admission notes and progress notes that the patient had a right lobectomy 5 years ago and NEVER has breath sounds on the right. You only have 2-3 patients in your care and none of them are particularly acute... take a second to flip through your patient's chart. 
  • If there are three nurses gathered at the nursing station gossiping and a patient's family member asks if he can have a glass of water, don't sigh loudly, roll your eyes and act like breaking up the gossip party is the biggest imposition in the world. 
  • You know I'm only here to round. You know that every time I come in, the first thing I do is ask the nurses if there are any urgent issues with their patients. Please be ready to answer the question. I know you've been on for three hours by the time I come in.
Some of these are minor complaints, I know. Except for the 'disregarding orders' thing. But the bottom line is the fact that these nurses just don't seem to care. Maybe I'm being naive, but I can't imagine someone with a job as important as a nurse simply going to work and going through the motions. And not even all the motions, as they seem to pick and choose the duties that they deem necessary and do the bare minimum in order to keep their jobs. The nurse manager says that she's so inundated with complaints against the nurses (from both doctors and patients) that dealing with them has become the primary focus of her job. She is planning to quit. 

The experience made me realize that no amount of money in the world will make me work in this environment. And it's no wonder they've had so many problems keeping physicians. And it made me that much more hesitant to take any emerg shifts there-- not when I feel like I can't trust the nurses.

Memo to hospital administration-- there's more to physician recruitment and retention than throwing money at the problem. Who'da thunk it. 

10 Comments:

Blogger MedStudentGod (MSG) said...

Must have been really bad to overlook the huge salary they were offering. That made my jaw drop to see that figure. Too bad...it seems like you've really got a good head on your shoulders for knowing where you're comfy and where you need to be careful. Many residents lose that as they get close to being done (at least what I've seen at my place).

But with all that being said - are you still doing the hospitalist moonlighting? The extra money is always tempting.

7:15 AM

 
Anonymous Anonymous said...

Wow... this is making me reconsider going back to school in nursing. I'm not sure I could work in such a poisonous environment.

4:10 PM

 
Blogger Couz said...

But that's just the thing... it's unusual that the environment WOULD be that poisonous. I've had such good experiences with nursing staff elsewhere that this place really stood out.

And MSG-- that figure isn't typical. It's a rural town that is designated underserviced by the government (and therefore eligible for incentive grants) and they're recruiting hard-core. I'm hoping to go back to the moonlighting as a hospitalist there when I'm back from mat leave, but I'd also like to get back into family medicine before I completely forget stuff like cholesterol guidelines and SSRI's.

8:26 PM

 
Blogger Nikki said...

Come to my town. :) The nurses are the BEST. (And they'll pay you well, too.)

11:18 AM

 
Anonymous sabrina said...

As a nursing student, I can tell you that accurate ins and outs are much easier said than done. I can't be in there every time he sips some water (or juice or milk or coffee or tea or jello or popsicles). He may drink 2/3 of the pitcher then his wife fills it most of the way full again and he drinks 1/4 of that. But the cup he has...did it come from the first pitcher or the second?

And for the outs...please do tell the patient how important it is that he pee in the hat and remind his family not to dump or flush it. They don't always listen to us. Somehow when it comes from the doctor it's seen as more important.

12:47 AM

 
Anonymous Anonymous said...

I also had to laugh at the accurate I+O thing. There isn't a patient alive without a catheter that will keep an accurate record. They all forget or dump the hat or lie outright especially when on fluid restriction. Doctors think nurses just live in the patients rooms waiting to count the pee..

Obviously this hospital has a problem. It is most likely patient overloading.
Look at the patient census a little closer...more likely your average nurse has eight patients not three and when someone goes to lunch they now have sixteen.
They probably have no system in place for doc orders or they have docs that put orders in and then put the chart back flagged but don't tell anyone about the new orders..this makes me insane. By the time I find the chart and notice the new orders it's hours later. Then you have to deal with the order entry system, then wait for a lab tech. So before you decide the nurses are just lazy good for nothings look a little closer.
Anytime you see pissed off nurses it means the system that should support them is broken very badly.
You made a lucky escape.
But you failed to see that it wasn't just nurses that were the problem..they were the most obvious symptom.
Another reason why they can't retain docs maybe?

4:14 PM

 
Anonymous Anonymous said...

A half million a year for a doc? No wonder health care costs are going through the roof. Perhaps they could pay the doc's a little less and spend it on implemeting some nursing programs instead. We also discuss who will pay for medical care but this proves that we also need to take a look at how much we are paying the docs. NO one just out of school deserves this kind of compensation.

3:19 PM

 
Blogger Lisa said...

With the nurse-experiences I have had this year alone, you'd have to pay me 500k as a patient to volunteer for that treatment again.

I have an intermittent CSF leak and I'm actively trying to heal it up at home rather than spend ONE day in the hospital, let alone the five my neurosurgeon quoted. NO FREAKIN' WAY. The nurse situation may be scary on your side, but it is nothing compared to some of the torture they've put me through. *yikes*

5:50 PM

 
Anonymous keepbreathing said...

Floor nursing is a problem. The motivated, intelligent and skilled nurses tend to hate floor work and so often wind up in specialty areas where they can really excel. There are exceptions, but where I work we have a lot of floor nurses who probably shouldn't be caring for patients.

11:08 PM

 
Anonymous Anonymous said...

to the person saying "no one out of school deserves that kind of money". Keep in mind they are doctors not engineers who has just 4 years of studying before a job.Docs are "learning" for 12 years plus before a "real" job as a doctor so they deserve to make good money, for all the years of hard work and the massive student loans to pay off. this really annoys me that everyone wants top notch service at hospitals but dont wanna pay the doctors what they deserve.

4:25 PM

 

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