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Notes on Shadowing a Hospitalist
- deleted 11mo ago[deleted]
- analog31 11mo agoAs 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.
- andrewrn 11mo agoWow. 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?
- AnimalMuppet 11mo agoNurses 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...
- andrewrn 11mo agoI will keep this in mind. I wonder if this culture could be broken somehow.
- FireBeyond 11mo agoI 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?"
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- jimnotgym 11mo agoIs 'Hospitalist' an American thing? I'm afraid the word grates on my European ears.
- andrewrn 11mo agoIt's widely used here state-side, yeah.
- 01HNNWZ0MV43FF 11mo agoNever heard it in my part of America
- AnimalMuppet 11mo agoI have, but only because my brother-in-law is one. If he weren't, I most likely wouldn't have heard of it either.
- WaltPurvis 11mo agoSimilarly, 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.
- rectang 11mo agoI learned it when a family member wound up in the hospital and had a hospitalist assigned.
- nradov 11mo agoHospitalist 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-hospitalist/ https://www.hospitalmedicine.org/about-shm/what-is-a-hospita...
- jimnotgym 11mo ago
- harimau777 11mo agoReading 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.
- dreamcompiler 11mo agoAlternative 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.
- alexpotato 11mo agoHighly 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] 0 - https://amzn.to/3KyLK1x https://amzn.to/3KyLK1x 1 - https://www.newyorker.com/magazine/2012/08/13/big-med https://www.newyorker.com/magazine/2012/08/13/big-med
- Rendello 11mo agoThis 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. https://www.newyorker.com/magazine/2011/10/03/personal-best https://www.newyorker.com/magazine/2011/10/03/personal-best
- cryzinger 11mo agoThat'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 https://www.newyorker.com/magazine/2010/08/02/letting-go-2
- seanhunter 11mo ago
- TimorousBestie 11mo ago> 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.
- faidit 11mo agoYeah. 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.
- toast0 11mo ago> 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.
- TimorousBestie 11mo agoYou’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.
- jbeus 11mo agohospitalist 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.
- kotaKat 11mo agoformer 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!).
- amypetrik8 11mo ago>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
- 11mo ago
- th3o6a1d 11mo agoI find these to be astute and fascinating observations. Thanks for the read!
- Waterluvian 11mo ago> 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.
- lordnacho 11mo agoI'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.