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.