Ins and Outs of a  Doctor’s Day

Who loses, who wins; who’s in, who’s out

Shakespeare (1564-1616). King Lear

June 9, 2012 - Preface: Occasionally I run across a blog post that vividly describes the daily life of a practicing physicians. Here is a post that is especially graphic and well-done. It is from the June 7, 2012, Well Blog in the New York Times. The author, Danielle Ofri, M.D.  is an associate professor of medicine at New York University School of Medicine and editor in chief of the Bellevue Literary Review. Her most recent book is “Medicine in Translation: Journeys With My Patients.

“The inpatient wards and the outpatient clinic are part of the same hospital where I work, but they are like different planets.

On the inpatient side, the patients are acutely ill — malignant brain tumor, acute renal failure, heart valve infections, intestinal bleeding, gravely low platelet levels, sudden-onset delirium, metastatic esophageal cancer, severe aortic valve stenosis, disseminated blood infection, liver failure, intractable seizures. Whenever I’ve started a month on the inpatient ward, I would always blanch the first time I’d look at my list of patients. After months in the clinic, I’d always forget how sick these patients could be.

Not so in the outpatient clinic, where patients get their regular medical care to manage everyday chronic illnesses like diabetes, hypertension, obesity and heart disease. The prosaic nature of these diseases by no means suggests that outpatient medicine is calm. It’s quite the opposite, in fact — a nonstop frenetic pace of too much to do in too little time. But it’s comforting to know that there is a low likelihood that your patients will drop dead on the spot.

Traditionally, internists practiced both outpatient and inpatient medicine. In fact, this distinction was never even made: Doctors took care of you when you came to the office and took care of you when you were admitted to the hospital. In some ways, this model is the ideal — your doctor was your doctor, no matter where you were or how sick you were.

I tried this for a short time early in my career, working in a private practice office while also taking responsibility for the patients admitted to the hospital. But medicine had ballooned into a round-the-clock, high-tech affair in the years since Marcus Welby, and the two sides of medicine were nearly impossible to balance..

I would get up at the crack of dawn to round on the hospitalized patients, then rush to the office for a full slate of scheduled patients. Throughout the day, I’d field calls from the nurses in the hospital: Someone’s potassium was low. A patient had new symptoms of nausea. A feeding tube was clogged. The M.R.I. results were back. Dialysis was canceled.

It was the worst feeling in the world, trying to focus on patients in the office while managing my hospitalized patients by phone until I could finish up, then racing back to the hospital for evening rounds. I knew I was doing a substandard job with both sets of patients, but I couldn’t be in two places at once. This was simply unsustainable.

This turned out to be the general conclusion of the larger medical community. Prodded by efficiency pressures from managed care and the reality that most internists couldn’t feasibly do inpatient and outpatient medicine at the same time, the “hospitalist” subspecialty was created — doctors who would work full time on the inpatient side, caring for hospitalized patients on the minute-to-minute basis that they require, ideally staying fully in touch with the patient’s primary care doctor.

For better or worse, the last 15 years have solidified this model. There are now some 30,000 hospitalists, not to mention a professional hospitalist society, specialized journals and academic meetings.

There are many critics of the new model, rightly pointing out that it fragments care even more. But having practiced on both sides of the divide, I think that it is impossible to return to the old-style doc who does everything. Each job is all-consuming, and the patients require full energy and focus. There really isn’t any way to do both well.

The medical center where I work moved toward this model a decade ago. Over all, it works reasonably well, though inpatient-outpatient communication has yet to reach the ideal. But if one of my own patients is hospitalized while I’m at clinic, I can breathe a sigh of relief that she will be cared for by one of my colleagues who is present, full time, on the ward.

The net effect is that the inpatient and outpatient care of our patients is shared among a group of physicians who, ideally, all know and trust one another. It’s not a perfect system by any means, but among the imperfect choices out there, it is probably the best.

Despite my years doing this, I still cringe when someone calls me a “hospitalist” while I’m on the ward. It sounds like I am taking care of hospitals rather than patients. (But I’ve already given my two cents about this.)

There are moments when I pine for the simpler days (if they ever actually existed), when patients could get everything they needed from one doctor. But that era no doubt had as many flaws as strengths. As I rummage around in my pockets, trying to remember whether I’ve left my stethoscope on the inpatient ward or back in clinic, I accept that we can’t choose the era in which we practice medicine, so we may as well make the best of what we have.”

Tweet:  The duties of physicians differ greatly inside and outside the hospital.

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