Thursday, March 13, 2008

Nobody in Charge

Hospitalists are physicians who work full-time in hospitals caring for inpatients. The specialty emerged because physicians found it inefficient to divide their work between the hospital and their offices and so preferred to turn the care of their hospitalized patients over to others; i.e., hospitalists.

When the specialty first emerged, I saw it as progress. It seemed to me that having a single physician or organized group of physicians care for all the patients on a nursing unit created opportunities for efficiencies through standardization of procedures – something that would have been difficult to achieve when the unit had to cater to the practice patterns of many physicians.

However, creating an opportunity doesn’t mean that it will be taken up. Somebody has to do it and in this case it seems not yet to have happened.

Take the example of friend Bill Busby as related to me in a recent e-mail.

“I had the misfortune a couple of weeks ago to be forced to enter the hospital for pneumonia. I took along with me both of my insurance cards and a two-page rendition of all of my medical history, my current meds and my physicians' names and phone numbers. My daughter, who accompanied me, also had a copy. Despite all of this ammunition, I can't believe the number of times I was asked for these data by a hospital staff member. They spent more time with this trivia than the doctor did in diagnosis or the X-Ray tech did in taking pictures.

Finally, after 4 days, the "hospitalist" came by to say I'd be discharged the next day. The next morning, some one removed the IV rack but not the hardware in my arm. Then someone removed the drip medication apparatus but not the mounting hardware. No one did anything about the catheter. After lunch, I began to wonder if they'd forgotten me. On a white board in my room were several phone numbers and a list of nurses--charge nurse, head nurse, nurse-nurse. I started calling the numbers. The first one I reached admitted that she was responsible for getting me cleared and that she was waiting for the doctor to sign a prescription for an antibiotic. What did that have to do with getting the hardware out of me so I could dress? Oh, it had to be done in a certain order. I called another number. This one said to call another. I did and voila the necessary people showed up to remove the hardware so I could dress. Finally nurse number one showed up with the prescription. She was very angry because I had interfered with her routine.”

Wife Marilyn recently had a somewhat similar experience trying to get out of the hospital after her three-day stay for a small stroke. She spent the first night in the ER because there were no beds. But the day of her discharge they couldn’t get things together until late in the afternoon – thus tying up the bed she was in.

The modern way of fixing that would be to assign the job to a group of the people responsible for the functions involved - including the doctors - working under common leadership and supported by management. That is still pretty uncommon in hospitals.

Or to put it in more traditional terms, nobody is in charge.

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