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August 4, 2008

Welcome to my world

Each summer, I welcome the new hospitalists, usually fresh out of residency, to my program. I treat them to an orientation where I share my accumulated pearls of hospital medicine wisdom. Because sports is a constant metaphor in my life, I like to think of it as the pep talk coaches give just before the beginning of the season. Here is a condensed version of my speech:

If you learn only one lesson from this speech, let it be this one: Be nice. Everyone is in this together, and goodwill pays off in both the short and long run. No patient wants to be in the hospital, no family member wants to worry about a loved one, and no nurse wants to feel like he or she isn’t respected as a caregiver and team member. I hope to hear that all of you are treating the nurses’ aides and the environmental services staff well. That's the best litmus test I have that you are, at least outwardly, a nice person, and that you have taken lesson No. 1 to heart.

Let me repeat: This is the most important lesson. So if you have a limited attention span, the orientation concludes here.

Able to see the big picture?
Still with me? Good. Lesson No. 2: Use your common sense and always strive to see the big picture. I would not have hired you if I didn’t think you have the potential to demonstrate common sense, because I have learned that it cannot be taught. You are either born with it or you cultivate it on your own, but no one can give it to you.

Trust me, I have seen some very book-smart doctors who just don't get “it”, and some not-so-brilliant ones who can pick up on “it” immediately. What is “it,” you ask? The fact that you even raise the question makes me a wee bit nervous, but I’ll give you the benefit of the doubt because you are new.

Here's an example: Having “it” allows you to walk into a room and know that a patient is sick without looking at a chart or lab value or even pulling out your stethoscope. You may not have a clue as to what is wrong with the patient, but you know, without a doubt, that there is something wrong, and that it’s time for you to do something about it.

Lesson No. 3: Allow for some levity on the job, but remember that there are times when laughter and wit have no place. We all need some periodic—and regular—lightness of mind; after all, we spend half of our days with people who are at death’s door. But we also need to know when to put the kibosh on jokes and get down to business. Your colleagues, your patients and your patients’ families will be grateful for the gravity you bring to your work.

"You will be sued"
Lessons Nos. 4 and 5: Document well. You will be sued. These are separate but not unrelated doctrines. As a hospitalist, your documentation is very much a value-added function.

To my mind, documentation too often remains an afterthought in medicine. I often look at a chart and, to employ a crude metaphor, am reminded of a dog marking territory on a fire hydrant. I know the consultant has seen the patient, but his or her scribble serves as little more than a code that says, “I was here.” I often have no idea what information that scribble is meant to convey.

For hospitalists, our note needs to provide much more than simply marking turf. The note is a plan that distills our thoughts and should guide the clinical ship. And, not unimportantly, it will help you and the hospital secure appropriate payment.

It bears repeating: You will be sued. At the end of the day, lawsuits are an unfortunate reality of our job. Being sued is not fun, to say the least, but you can’t let fear of litigation govern every decision you make. And guess what? If you document legibly that you have practiced the standard of care for a case in question, you can rest much easier.

Look hard at that greener grass
Lesson No. 6: You will undoubtedly be frustrated by the fact that being a hospitalist is both a job and a business. But keep in mind that the grass is not always greener at the next hospital. If I acted on my desire to call it quits every time I felt that I had been wronged, I would probably be on my ninth job by now.

Understand that the $200K+ you could probably get next door may seem great, but in reality you’d find yourself realizing that they couldn’t pay you $1 million a year to make it worth your while. Remember too that, if you do decide to leave, you should never burn a bridge. There may be 25,000 of us, but we remain a small community.

Finally, please recognize that health care is a finite resource. Just like the liquid byproduct of dead dinosaurs, health care has a VERY limited supply, and the demand is only increasing. Indeed, the health care well right now is running dry, which is why it's currently in a state of financial crisis. Perhaps the greatest contribution our profession can make is to keep asking—and acting upon—this all-important question: “How will this intervention or test change treatment or the patient's outcome?”

That’s it. Now go get ‘em!

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6 Comment(s)

The Happy Hospitalist wrote:
A great read, if I must say so myself
Anonymous, USA | Wed, Aug 6 2008 08:17 AM

ARNP Hospitalist wrote:
I love it! Can we use it in our group as "this is something you should read" when our new hires join?? Fri, Aug 8 2008 20:55 PM

Dirk Stanley wrote:
As another hospitalist in the trenches, these are all good lessons and reminders. Too true.
Northampton, MA | Mon, Aug 11 2008 07:24 AM

Erik DeLue wrote:
Thanks ARNP and Dirk, I appreciate the feedback. Please feel free to reproduce this piece at an orientation, I would be honored, and besides TH's copyright infringement lawyer was recently disbarred.

If there is anything I should add to my speech next year, I am always looking for the expertise of others.
Mt. Holly, NJ | Mon, Aug 11 2008 08:13 AM

Anonymous wrote:
Few things crossed my mind.

The generalisation that no patient wants to be in the hospital does not ring true when it applies to the large number of drug seeking patients that hospitalists have to effectively fight to discharge.

The all-important question is an unrealistic approach to practice when an ER graduate from Johns Hopkins insists on an admission since she is concerned about the 0.05% cases she could miss from a negative study and that too in a patient with atypical history and negative findings.
Baltimore, MD | Fri, Aug 22 2008 11:11 AM

Erik DeLue wrote:
Thanks for your comments. I agree I took some artistic license in the generalization that ALL patients don't want to be in the hospital. But I would still argue that it's not an incorrect generalization to say that rule No. 1 is to be nice all the time.

Even if a patient is addicted to narcotics and, as a result, manipulative, that doesn't necessarily mean that you can't still be empathetic. There are ways to say no to IV dilaudid--"time to go home"--while still being "nice" about it. Granted, the drug seeker may be too blinded by his or her addiction to realize that you have created limits while still treating them with compassion, but that does not negate the be nice doctrine.

As to your second point of frustration, stay tuned for a future blog, I believe I have solved the elusive "that clueless ER doctor handed me another soft admission" problem. OK, I will admit ahead of time that my solution may be a bit of an overgeneralization, but stay tuned nonetheless.

Mt. Holly, N.J. | Fri, Aug 22 2008 13:40 PM


About Erik DeLue, MD
Erik DeLue, MD, examines the challenges of running and reinventing a hospitalist program. He is medical director of the hospitalist program at Virtua Memorial, a hospital in Mt. Holly, N.J.

This is the third community hospital program that Dr. DeLue has worked for in his nine years as a hospitalist. Join in the dialogue on issues that range from compensation and 24/7 scheduling to how to work with competing hospitalist groups.

The opinions expressed by Dr. DeLue are his own and do not necessary reflect the opinions of his employer or Today's Hospitalist.
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