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Welcome to community medicine

October 2008

Published in the October 2008 issue of Today’s Hospitalist

MY FIRST JOB AS A PEDIATRIC HOSPITALIST was at a midsized community hospital in a Midwestern suburb. It was also my introduction to the world of community medicine. Having trained at a large children’s hospital and then continued post-residency work at another university-based children’s hospital, I ran head-on into some major culture shifts in my first position.

From the beginning, it seemed that we fell into two distinct groups: the office-based pediatricians and the hospitalists. We seemed to be operating on different wavelengths, and I frequently found myself wishing the two groups could come together.

Tuck-in services and social rounds
We found, for instance, obvious problems with the frequent practice of admitting patients to the hospitalist service overnight and then transferring them to the primary care physician the next morning. The introductory opinions and recommendations given overnight by the hospitalist to the patient’s family were sometimes revised or significantly changed. While we all agree that there is more than one right way to do most admissions, this practice led to poor patient satisfaction scores and confused nurses.

Occasionally, a primary care physician would perform social rounds. Now, I believe this makes a lot of sense, letting parents see a familiar face and allowing hospitalists to get some “insider information” from the office-based physician regarding details the family may not have been open about during admission. However, there were a few times when primary care doctors would talk to the family and call in their own consults and order tests. At the end of the day, that would leave the hospitalists responsible for actions that were not theirs to begin with.

Not on the same clinical page
We also didn’t see eye to eye on some issues related to clinical decision-making, such as specific choices of antibiotics or whether to give any antibiotics at all. Should routine chest X-rays and complete blood counts be ordered on typical RSV bronchiolitis patients? Should they all get albuterol for wheezing? And here was my least favorite situation: Sometimes, administrators were called in and asked to get involved because of a conflict over medical issues.

Now, it certainly was not all complaints, and practicing as a pediatric hospitalist in that hospital was a great learning opportunity. I learned how to call the surgeon to tell him that I had a patient with appendicitis (before the CT scan and labs) and that, if he was comfortable, he could schedule the OR slot as he came down to see the patient.

I learned which radiologist was OK doing the difficult lumbar puncture under fluoroscopy and which one would not even give it a second thought. In the community hospital, away from all the extravagant support of specialists in the university setting, I matured and grew judicious in my practice of medicine.

In addition, working with the ancillary staff daily gave me the keen advantage of knowing everyone’s style of work and who I needed to monitor or not. For example, there was the one respiratory therapist who refused to use the mask for albuterol and preferred “blow-by.” Then there was the nurse who would prefer to get an axillary temperature (as opposed to rectal) on the 2-week-old febrile neonate, because she didn’t want to wake the child. As the hospitalist, the phrase “keeper of the ward” frequently would come to mind.

Common ground
What was my final read on my first community position? Community inpatient medicine has its challenges, but in the end it is worth the fight. It is crucial for the hospital and administration to set up an environment that will allow both groups of physicians “office-based doctors and hospitalists “to feel valued and respected. Encouraging both groups to meet and discuss ideas in journal clubs or around monthly evidence-based medicine topics might help each group appreciate the knowledge that the other brings to patient care.

That also might help office-based practitioners accept more readily that we are “hospital specialists,” even though we do not have a separate fellowship, and that we have something significant to add to the care of their patients.

And to all residents who may be considering a career in hospital medicine, it is important to understand the differences in practicing in an academic vs. community setting. Each setting has its own issues and rewards, so make sure you are ready to take on the challenges of the setting you choose.

Lavanya Shankar, MD, has been a pediatric hospitalist for three years. She currently works at Children’s Memorial at Central DuPage Hospital, located in a western suburb of Chicago. Check out her blog and others at the Today’s Hospitalist Blogs site.