Notes on Shadowing a Hospitalist
humaninvariant.substack.com71 points by surprisetalk 2 days ago
71 points by surprisetalk 2 days ago
Highly recommend reading Atul Gawande's "Checklist Manifesto" [0] if you are interested in the operational results of adding something like checklists to medical care.
Case in point: requiring everyone in the operating room to say their name, specialty and reason for the operation (and their part in it).
You might ask why the above is necessary?
Well:
- everyone is wearing a mask, cap and possibly glasses which makes them hard to recognize
- the patient is often draped in such a way that you can't tell who they are
- many Operating Rooms(ORs) look the same
- there are apparently COUNTLESS stories of medical personnel going into the wrong OR and not realizing until the surgery has started
Another fascinating point about checklists since the OP article mentions doctors vs nurses: checklists give nurses the power to challenge doctors. e.g. "Dr, I believe the next step on the checklist we agreed on is to do X".
If you have no checklist, the Dr can just say "No, we don't need that, I know what I'm doing. Shut up, Nurse!" (this is a real example from the book btw).
He also has an article comparing the Cheesecake Factory to health care that I also highly recommend [1]
This reminds me of an article I read [1] where a surgeon, deciding his skills had room for improvement and lives could be bettered by honing those skills, had a retired surgeon come in occasionally and coach him. The external perspective and quick feedback improved his confidence and outcomes, and he convincingly advocated that practice.
That's also by Gawande! (And a great article, too.)
If you liked that, here's my own recommendation for something he's written: https://www.newyorker.com/magazine/2010/08/02/letting-go-2
Another similar example of process excellence in healthcare from personal experience: I had to have two shoulder surgeries (one on each side) a couple of years apart after ultrasound-guided injections into the joints didn’t really fix the underlying problem. In both cases I used the same surgeon[1] and both times on the day of the surgery (in spite of having been involved in my care for months so she definitely knew) she asked me again which shoulder was affected and immediately rolled up my sleeve and drew an arrow on the arm in question in black marker pen.
Why? Well she definitely didn’t want to ever make the mistake of operating on the wrong arm, and if I’m anaethsetised it’s not like she couldn ask me while the procedure was underway.
[1] Susan Alexander- She’s absolutely amazing. If you have shoulder problems and live in the UK I would strongly recommend.
As I'm in my 60s, I have elderly friends and relatives who have spent time in hospitals and rehab facilities. The patient needs to have an advocate who is informed of their situation and is present when the doctor makes their brief daily or weekly visit. I've seen decisions made, that contradicted the information in their "chart" such as exercise sessions for a person with a documented broken spine, treated as inviolable by the nurses and other clinical staff. Only the doctor can change the facts of the case.
What I suggest is that if you have a friend or relative visiting you, they should bring a "flip chart" -- the old fashioned 2 x 3 foot pad of paper -- and write down in huge letters the most important details of the case. Ask the doctor to help you fill it in.
> 1. Everyone jokes about death
I spent most of my life perceiving comedy to be one of the less serious art forms. “You can make a beloved film but won’t win a Best Picture award” kind of less serious.
But I read sections like this one, and I experience the use of comedy for community-building and healing and discussing politics safely. And I’m growing a belief that it’s the highest, purest, most honest form of communication we have as a species.
We want to make death less taboo, but what we really need is to make joking about death less taboo.
Wow. Fascinating article. I am an engineer in a family that is otherwise purely medical (mom nurse, dad pediatrician, sister veterinarian).
Over the years I hear a lot of their pain points, and EMR's are consistently very painful for my boomer parents who are not tech savvy (my understanding is that it's not an age thing, though).
I have personal experience with pt. 8: Doctors know who's good, they just won't tell you. When I had a meniscectomy with poor results, none of the orthopedists I visited after the surgery would comment even lightly on the appropriateness of that procedure given my symptoms and MRI. This isn't different to other professions, where you generally have nothing to gain from badmouthing colleagues, but its incredibly painful that thousands of people are prevented from good care because of this meritocratic breakdown.
As a totally separate point-- this format of shadowing notes in incredibly compelling! I've been shadowing chemistry and biology wet-labs lately, and I wonder if making similar writeups would be interesting to others?
Nurses know, too; they just can't tell you because they are not licensed to give medical advice.
Once, in a situation when we really wanted an opinion from a nurse who wouldn't give one, we finally asked, "If it was your daughter, what would you do?" With no hesitation, she told us exactly what she would do. She just couldn't tell us what we should do.
That phrasing has proven to be useful a time or two since then...
I asked my attorney after a bad accident (that despite 100% liability being accepted by the other party, my insurer was still treating me like I was the problem and a bother to them) who he recommended as an insurer. He said much the same thing.
So I said, "Well, leaving aside recommendations, who do -you- use as your auto insurer?"
> Doctor competence is highly variable, as there are few incentives for improvement.
> But all hospitalists are paid under the same schedule (based on years of experience), meaning that the high-agency hospitalist is getting paid the same as their counterparts. Greater intrinsic motivation and competence are not explicitly rewarded.
I find it very hard to believe that it’s possible to measure “greater intrinsic motivation and competence” objectively here (and for GPs as well, basically any profession with high variety in the Stafford Beer sense), so explicitly rewarding that seems fraught with Goodhart-style problems.
Yeah. Minimizing patient days spent in hospital was also mentioned as a metric. Sure that may be good for some reasons (eg avoiding iatrogenesis) but incentivizing it could lead to patients being sent home too early instead of receiving proper care.
They also mentioned surgeons being "top of their list" - what list? Surgery success rates? That's widely understood to be a problematic measure. Surgeons can boost their success rate by only doing easy operations. Conversely, a surgeon who operates on the most at-risk patients will get a lower success rate because the patients' chances of a good outcome were bad no matter what. Regardless of how good the surgeon actually is, which might be impossible to measure objectively.
> Minimizing patient days spent in hospital was also mentioned as a metric. Sure that may be good for some reasons (eg avoiding iatrogenesis) but incentivizing it could lead to patients being sent home too early instead of receiving proper care.
You usually combine a minimize days in hospital goal with a minimize readmittance goal. And combine with supervision to ensure low readmittance isn't due to patients being admitted to the morgue instead. Ideally, some longer term measure of patient outcomes. But as you mentioned, you also need to account for the mix of patients.
You’re describing the vicious cycle of Goodhart’s law. The one measuring the metric adds epicycle after epicycle while the one gaming the metric develops ever more subtle strategies for subverting it.
hospitalist here - I think “everyone hates epic” is a major over-generalization. If you have worked with one implementation of Epic, you have worked with one implementation of Epic. It probably does not meet the standards of popular modern software, but it is complicated. If it is implemented as a replacement for paper charts, it can be terrible. If it is thoughtfully customized to support common and important workflows and support high quality care, it can be a life and efficiency saver.
former hospital IT; also agreeing major generalizations with "everyone hates <the EMR>".
Everything comes down to the implementation at the end of the day. We've had people come into our Meditech 6.x shop from other shops (Cerner, CPSI, MAGIC installs) and comment how much Meditech was an upgrade, and I'd see Epic users complaining about the downgrade all the same.
The entire region's gone up to Epic now thanks to mergers from larger systems, and every site that had everything prior now (especially that crummy little CPSI system) agrees that Epic is now the best thing since sliced bread.
Coming into it though finding out just how much lives in the system... wow. I was amused to see that HR very much lives alongside nurses in the same system (Meditech's HR modules... and an employee portal that quoted copyrights from 1995 from Photodisc!).
>Everything comes down to the implementation at the end of the day.
To convert this context from medicalese to technese - when a hospital (system) buys an EMR (medical record system), it's like purchasing a very fancy version of "vim" or "emacs"
As all of you know, vanilla vim or emacs can be a very different experience from a polished and tuned up config file version.
So doctors are at the whims of their hospitals high (or often low) quality vim/emacs config, or .rc file of your choice - that's what "implementation" means
Some systems like Kaiser are famous for having super duper special high quality epic configuration, making epic famous for quality, though implementations (vimrc) in other hospitals, most other hospitals, is shite
Is 'Hospitalist' an American thing? I'm afraid the word grates on my European ears.
Hospitalist is a recognized medical speciality with their own national society and NUCC provider taxonomy code 208M00000X.
https://www.hospitalmedicine.org/about-shm/what-is-a-hospita...
Thanks, but that doesn't really answer my question. It demonstrates that it is a thing in America, but for it to be an exclusively American thing I would really need some confirmation that it is not widely used in other places. Cheers for whoever downvoted, would love to understand why asking a question gets a downvote?
For another data point, I'm in Australia and with quite a lot of medical contacts (my wife is a speech pathologist, sister an anaesthetist, and have friends who are nurses), I've literally never heard the term until seeing this HN title either.
A senior generalist hospital doctor.
They aren't traditional specialists but for pay / prestige / political reasons they are recognised as specialists (to recognise their level of training and experience and the importance of their role).
It grates on my American ears as well. Never heard it before this article, and I'm hoping it's a fad word that won't leave southern CA.
I first encountered it in 2009, in Seattle, when I spent time in a hospital. I'd never heard the term before...but then, I'd never spent time in a hospital before, either.
Quite common across the US. It's a doctor, usually trained in internal medicine, who does not see patients in a clinic. Only in the hospital.
Very few general medicine doctors see clinic patients and hospital patients these days. In subspecialties, it's still common to do both, but we've started to see OB hospitalists, and it's not unheard of for surgeons who have aged out of doing surgery (malpractice insurance becomes onerous to obtain in procedural specialties after age 70) to continue working in their former practice as clinic-only doctors, which allows the younger ones to stay in the OR (which is where the surgeon makes almost all of their money) rather than run back to clinic fifteen minutes down the road to see routine follow-ups.
Any X-ist name now grate my ears, especially when it's new. Always seems like an ugly patchwork before a "proper" name is coined.
Never heard it in my part of America
I have, but only because my brother-in-law is one. If he weren't, I most likely wouldn't have heard of it either.
Similarly, my sister-in-law is a hospitalist, so I've come to consider it a commonly used and widely known term, but now that I think about it I don't believe I've ever heard anyone use the word except in conversations with my sister-in-law and brother.
I learned it when a family member wound up in the hospital and had a hospitalist assigned.
Yes, and the term didn't exist 30 years ago. It's a relatively recent thing, but very widespread now. https://en.wikipedia.org/wiki/Hospital_medicine
I've often thought there should generally be more work-shadowing. Not just from young people looking for a first job, but from all sorts of cross-professional and seniority groups. I think there would be a lot of benefit from seeing how some random other person does his job.
Another aspect is automation development. Particularly for people who are supposed to be writing tools for another profession, it's worthwhile spending time getting some notes like thing.
Reading this, it's not surprising why alternative medicine remains popular. Generally, the practitioner both acts like a human and treats their patient like a human. That doesn't appear to be the case in a conventional hospital.
Alternative medicine may be attractive because it seems more personal, but we have a one-word description of people who seek alternative medicine for serious conditions like cancer: Dead.
I find these to be astute and fascinating observations. Thanks for the read!