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Getting up to speed

April 2011

Published in the April 2011 issue of Today’s Hospitalist

"I didn’t get home until 10 last night. It takes so long for those admissions …"

That was a constant refrain from a new partner who was three years out of residency “and who had finished her training before the limits on resident workloads took effect. But she had never figured out how to admit and round on patients efficiently. As a result, she got seriously burned out and had to find another practice. Worst of all, the care she gave patients wasn’t any better than what the rest of us provided in far less time.

Sound familiar? Or is this the kind of comment you keep hearing about a colleague: "Joe knows his stuff, and I don’t want to force him to change a style that he’s comfortable with …" That shows a commendable professional respect, but if Joe still has five patients left to see at sundown, some of those patients have waited a long time between visits or have had something important delayed. Your group’s length of stay statistics suffer, along with perhaps your patient satisfaction scores. And while Joe is dotting every "i" and crossing every "t" on the vertebral fracture patient, what’s happening to the GI bleeder down the hall?

New hospitalists may not realize that prioritizing is a key part of the job and that seeing everybody in a timely fashion should come before they fill in all the details. If one of your group members is clearly not able to provide care as efficiently as the rest, you may want to review a few of his charts and look for things you can gently correct: overly long dictations, time spent on problems that should be managed in the outpatient setting, extra hospital days that could have been avoided if tests and consults had been ordered sooner.

While you’re at it, take a hard look at your own work habits and see if there are ways you could work more quickly. When our expanding hospitalist group showed early signs of not practicing efficiently, the two senior docs started looking for tricks to teach the newbies. Here are some ideas that we came up with that may help other hospitalist groups.

Start with discharge?
New docs need to be aware that discharge planning begins on the day of admission, so spend part of their orientation encouraging them to discuss plans with social workers and case managers early. Also, the concept of "acute care criteria" may be new to them. Explain that keeping patients admitted after they no longer meet those criteria can lead not only to charges being denied, but also to big insurance headaches for their patients.

Remember that residents rarely interact with case managers and social workers as much as you do, so introducing a freshly trained doctor to these key team members can be an important part of their education. If they feel guilty about "pushing the patient out of the hospital" or insecure as to when to discharge people, encourage them to ask for advice and suggestions.

Discharges are tiring and time-consuming because of everything that needs to be done: note in chart, med reconciliation form, summary dictated, prescriptions written, billing info recorded, etc. Giving new docs a simple checklist (see "The discharge mnemonic," below.) will prevent extra phone calls or trips back to the nursing station because they forgot something. Point out that it’s entirely OK to bill for a long discharge even if the work is done on more than one day. It’s also fine to write prescriptions or transfer orders a day or two ahead if you know that tomorrow will be busy or you want to make it easier for the weekend rounder.

Write the history as you take it, and other heresies
As a med student, you took copious notes and ever-so-carefully rewrote them into your report. But by the time doctors finish their training, they know enough to concentrate on pertinent positives and negatives in both the history and the review of systems. If you’re writing the history of present illness as you talk with the patient and/or family, you can keep the conversation in chronological order rather than skipping around from past to present and getting a lot of irrelevant comments.

Filling out a form helps too. Our group is trying out a one-page template that covers the elements of a history and physical. If the patient digresses into explaining that the pain is where he had surgery last year, you can skip down on the form to "past medical history" and jot that down, then go back to the current symptoms. Avoid unnecessary questions: When you see a pack of Winstons poking out of a patient’s shirt pocket, there’s no need to ask if he smokes, just how much.

You also don’t need to discuss many past events if somebody else has already noted that information. If Mr. Wheezer told the triage nurse he had an appendectomy at age 16, he’s unlikely to tell you anything different. And if the nurse wrote down all his meds and dosages, you can just show him the list and confirm that those are the drugs that he’s still taking.

Keep simple things simple
Not every patient needs three pages of dictation. The young guy with the snakebite and no other issues needs fewer questions than the old lady with multiple problems. If the patient has been intubated, you don’t need to rush to try to find out every minor complaint she had in the last week. Instead, you can wait till she wakes up, dictate "review of systems unobtainable because of intubation," and use that time to call the intensivist and make sure breath sounds are equal on both sides.

Give your overly-conscientious new physicians examples of patients they can admit and manage with a "short form": low-risk chest pain, healthy young ladies with uncomplicated pyelonephritis, or consults for diabetic management in patients who already have a specialist for every organ system.

The dictation game
It’s not unusual to see a full-page admit note on a patient accompanied by "H&P has been dictated." But by this time tomorrow, that transcribed H&P will make the admit note unnecessary. Why not use your admission note only for what can’t be gathered from the computer or others’ notes?

And while dictating the H&P, jot down pertinent info from the HPI, scribble additions to the nurse’s record of past history, and write only pertinent positives and negatives under review of systems. Next, add only the physical findings and the very few lab tests that are relevant to the illness.

Now sit down to dictate, with the EKG in front of you and the computer displaying lab and X-ray results. Goes faster, doesn’t it? Better still, have the order sheet nearby so you can add items as you think of them.

Pre-planning your rounds
If you have a large hospital or many patients, plan ahead. Put an "E" (for early) by the guy with the midnight pneumothorax and the lady you want to see before her endoscopy, and "L" (for late) for the stable thrombosis patient who’s just starting Coumadin, isn’t very sick and is not going anywhere soon. In between are the M-for-middle patients. If morning labs might affect somebody’s place in that line-up, check those now.

What else can you do from your desk? Your consultants will be grateful “and they’ll see patients sooner “if you call them early in the morning, so make those calls now. If you want to hear how a problem patient did overnight, you’d better phone the nurse before 7:30. Also find out if the OR or endoscopy suite has an estimate for when a patient’s procedure will be done and try to see him either before or after. That way you’ll avoid making a second trip to see someone who’s out of the room when you arrive the first time.

Now it’s up to you. If most of your Es are in the south tower, start there. Or maybe visit only the Es wherever they are, and then start rounds all over again for the rest. But if an L is next door to one of the Es, you can drop in and save yourself a second trip. With practice, you might even manage to arrive at the cafeteria just when you get hungry.

Clinical teachers may have made your younger doctors afraid to go to the second patient before they’ve done everything possible for the first one. Encourage your partners to do essentials first and to treat other chores “like calling the primary care doctor or checking endoscopy results “as "later on" jobs. Otherwise, someone on their "L" list may present with an unpleasant surprise that could have been avoided if the patient had been seen sooner.

Start the note, then see the patient
Yes, the SOAP note begins with the patient’s report on how she is doing. But it’s a rare patient who won’t ask about test results or how her blood pressure is running. Be prepared before you enter the room by reviewing the newest information on the patient’s condition, and then write that into the progress note before you enter the room.

Your note will have some blank lines at the top, followed by vital signs and probably O2 saturation, then a blank for physical findings followed by test results. If you can fill in part of the assessment “his diabetes is better controlled, the anemia responded to transfusion “fill that in now, along with whatever plans seem likely.

Now go see the patient. If he surprises you by reporting hematochezia for the first time, you’ve left plenty of space on your note. Fill it in, order whatever is appropriate, add "LGI bleed" to your assessment and "monitor H/H" to your plan. Then call the gastroenterologist “and move on.

Tricks of the trade
You may want to give your cell number only to treasured consultants; I also give mine to ICU nurses and case managers, but that’s your call. If you learn another physician’s cell number, however, write it down, because his answering service will without fail have an off day just when one of your patients needs an emergency consult or procedure.

Forgotten paperwork should not mean an extra trip. Prescriptions can be phoned in, out-of-hospital DNR forms can be faxed and so on. Live better electronically.

Once you’ve seen a patient and completed all the necessary chores, put a check mark by his name. Don’t worry about him again unless you’re called. You will review his problems again, but only at the end of the day.

Consider hiring an administrative assistant. You are busy enough with patient care, and you don’t need someone with a medical degree to track down insurance data and assemble third-party paperwork. Getting help will pay off not only in saved time but in preventing burnout. You want to keep those new docs happy enough to stick around so you don’t have to train even newer new ones.

And if you or a colleague is afraid that patients will feel short-changed by short visits, then sit down. Really, sit down. Patient satisfaction studies have shown that patients overestimate the time a doctor spends with them if the physician sits down to discuss their situation. You can improve your approach further and signal that the visit is ending with a single question: "Is there anything else?" Even the most long-winded realize that you’re caring for other sick people “and that gives them the chance to blurt out something important that they may have hesitated to mention, before it’s too late to fix.

Working smart
Hospital administrators already realize that patients often lose more than they gain from extra inpatient days, which can cause problems ranging from deconditioning to nosocomial infections. Ineffective use of physician time can delay necessary care or lead to payment denials. Encourage your new partners in their good habits, but help them see that quality of care and quantity of time are not always the same thing. Your patients will benefit as much as your group will.

Stella Fitzgibbons, MD, received two engineering degrees before she started medical school, and those degrees prejudice her on the side of efficiency. She is an internist who has been a hospitalist since 2002.