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October 22, 2010
A day in my life

I was intrigued by the recent time-motion studies out of University of Michigan and Northwestern respectively. As noted, they found that hospitalists spend only about 15% of our time on direct patient care. Looking at the Michigan study in particular, we spend 79% of that 15% slice of the pie on the initial history and physical. Talk about the importance of first impressions; it doesn't appear we are spending a lot of time on future ones.

Another striking finding was that we spend almost a third of our day on documentation. That's no surprise when you look around any medical floor and see the vast majority of doctors, head down, typing away on a computer or writing some illegible hieroglyphic.

For those like myself stuck in the world of illegible scrawl, I didn't note any data on how much time we waste trying to decipher the written word of surgeons or other specialists. And for those fortunate enough to live in the digital age, I do wonder how much time we lose trying to find useful information in template-driven notes that are geared more to CMS billing guidelines than the delivery of crucial, useable information.

Having been a hospitalist for many years, I did note that those studies, while excellent and very believable, failed to describe a significant portion of indirect patient care. Actually, "indirect patient care" might be a too strong of a characterization for the categories that I'm about to review. A more descriptive grouping would be: "directly related avoidance of indirect, direct, and anything resembling patient care." What follows are my big three, but I am sure any hospitalist worth his or her salt can name many more:

● Shooting the Bull: I mean, we work with these people every day, and I see most of my colleagues more than I see my wife and kid, so naturally not a day is spent without significant bull you-know-what being discussed. In fact, this is often the favorite part of my job. How else would we survive our daily craziness? That said, I have worked with doctors who actual specialize in this behavior, pushing their direct patient care meter well south of 15%.

● The "Work Workaround": Otherwise known as avoidance of actual work, no matter how much work that takes. The classic scenario is the ER admission that you just don't have the energy to admit. Typically, it is a "weak" admission and so the culprit hospitalist devises an elaborate strategy to sabotage the ER doctor's attempts to have the patient admitted.

The diversion has much too-and-fro but the end game is always the same: The patient is admitted, and a tremendous amount of time has been wasted. The more sinister form of the Work Workaround comes in the form of a hospitalist who wants to avoid work at the cost of others. What is always so mind-numbingly frustrating is the fact, and I know some brilliant physicist has a formula that proves this theorem, that the time wasted avoiding work is always twice as much as the time that ends up being spent if the work was just done in the first place.

● Time spent complaining: Maybe this one is really an amalgam of the first two, but let me say a little more about it. On the one hand, I believe this was a skill set forged in the days of the residency I knew oh so well: no work hour restrictions. We oldtimers had plenty of reasons to complain, and we honed those skills on many a q3 call without any prospect of leaving the hospital within 18 hours. However, despite residency reform, this trait seems to be alive and well. Maybe it is just in our DNA.

Perhaps the time-motion authors will reexamine their cohorts with an eye toward my comments, and then again perhaps they won't. My only request—make that "plea"—is that they never do a time-motion study on hospitalist medical directors. Remember, we were the ones who invented the Work Workaround while you were still dealing with acne in junior high. And in our current position, we have mastered this high art. I certainly don't want that fact coming out!
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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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