Monday, March 06, 2006

Too Damn Lazy.....
Dr. Parker spends a great deal of time on hospital committees. I attend six regular committee meetings a month at Big Hospital. The newest addition to my toils is the Critical Care Multidisciplinary Committee (CCMC). Big Hospital is trying to make some major improvements to the delivery of care to really sick people.
One of the first things on the agenda was about physician supervision of the housestaff. Big Hospital has a Family Practice residency program, and these residents cover many services. The Staff Medicine service (the main target of this proposed policy) is staffed 75 percent of the time by private attendings, the other 25 percent by the sole hospitalist. These attendings are either FP's, primary care IM's, or medical subspecialists. They rotate two weeks at a time and are compensated for their teaching. They also bill and collect through the hospital. The CCMC felt that such supervision was lacking, IMHO it was totally non-existent. Motions were made and seconded and amended. What came out was a policy that read in part:
A patient requiring admission to the intensive care unit must be evaluated by the attending physician within four hours of admission.

Reasonable, no? Certainly a patient ill enough to require critical care is ill enough to require evaluation by their attending physician, the physician ultimately responsible for their care. Aren't they?
Before this went to the medical executive committee this went to the internal medicine committee for their input.
It was akin to somebody dropping their pants and leaving a steaming pile on the conference room table. Physicians came with resignation letters for the teaching staff. The hue and cry was such that the chief of internal medicine promised to try and get it changed.
The chief then brings his concerns to med exec. I was at this meeting as he relayed their concerns. He and I went back-and-forth. His fist point:
The patient was seen by an ED physician and the resident, and that should be enough.
It is not the ED physicians responsibility to formulate a treatment plan for a patient, but to diagnose immediate threats and stabilize the patient. Taken to a logical conclusion this reasoning would allow the ED physician to become a "uber hospitalist", or eliminate the ED physician entirely and have the on call guys sitting around the ED an have the patients triaged to them.
Second point:
The medical specialists have little to add to patients whose conditions lie outside of their field. The example given was a gastroenterologist caring for a patient with chest pain.
My rebuttal points:
1) If boarded in IM and your specialty (as some are) that argument is a Non sequitur.
2) This would imply that the knowledge base of a first or second year FP resident trumps your years of experience in giving a patient heparin, nitroglycerine, and aspirin. Yes, such decisions about catheterization and thrombolytics are best reserved for a cardiologist, but the input of an experienced attending can avoid errors of omission and judgment. So you can at least keep the resident from screwing up. (When this was brought up he was unable to agree to that with a straight face)
3) If you feel uncomfortable handling those patients, maybe you should not be on the call roster.
My final point was to bring up the old "properly supervised housestaff can do no wrong" quote.
I was later told that an additional point had been brought up that the physicians in question had no problem with such a policy for private patients, but would not agree to this for the staff patients. Hence the title of this post. These are the same physicians who piss and moan about how bad the residents are. Well based on their behavior I can't really hold the residents fully responsible since those that are supposed to be teaching them can't get into the hospital to see a critically ill patient within four hours. When those who are supervising them refuse to take their calls in the middle of the night, or are so loathsome when called they create a culture of fear in the residents. When a resident pleads for help and is told to "do what you can" and "I'm not coming in". What a wonderful example we are setting for them.
Such is the rant bottled up over a long weekend of call. I'm sure you have stories of lazy as hell surgeons as well. Post'em in the comments. I'm going to take a nap.
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