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Drowning in cognitive scut?

May 2010

Here is one of my biggest fears for hospitalist medicine: As we become all things to all specialists, we may find ourselves less involved in the actual decision-making that guides patient care.

I have no doubt that we will never lose our value in correcting potassiums of 2.9, nor that there will come a time when we will no longer be involved in signing restraints or pronouncing the dead. What I do worry about is that this type of work, even though it’s important to the day-to-day operations of any hospital, will start to overwhelmingly define our role as physicians.

The phrase that comes to mind is “scut work,” a term that dates from our days as interns. Placing IVs and drawing blood cultures were examples of such work, sunk as they were at the absolute bottom of the hospital’s hierarchy of tasks.

While I suspect and hope that most hospitalists out there are not stuck doing these jobs, I have a feeling that we are being saddled with something that might be called “cognitive” scut work. I don’t mean that replacing potassium is on a par with placing IVs in terms of the demand on a hospitalist time and attention; how much time and thought does that take? But K+ replacement is just the tip of the iceberg as far as this new form of scut.

To wit: The average patient is on at least 10 medications. Multiply that by the number of admitting orders and discharge MARs, and we’ve got plenty of cognitive scut to occupy our time before making any treatment decisions. Then multiply that average patient by increasing patient loads and shortened LOS, and you have one busy hospitalist.

The result? We are left with less time to do real medicine and to make decisions that directly affect treatment and care. Instead, that work winds up being outsourced to consultants.

That’s not always a bad thing; patients ought to be treated by those with relevant expertise to ensure standards of care. I, for one, am not a tuberculosis expert, and I will readily cede those treatment decisions to my infectious disease colleagues. But I’m not ready to cede all decisions all the time for all my patients.

A good barometer of whether you are seen as the decision-maker for patient care is whether it is common practice at your hospital for consultants to consult consultants. If my renal consultant walks in and finds an acute abdomen, I of course expect a call. But I don’t expect him or her to wait for my approval for a surgery consult.

Yet throughout my career, I have found that a lot of cognitive outsourcing occurs between consultants that leaves hospitalists out of the loop. TSH elevated? Cardiology decides to call the endocrinologist. SOB? ID consults pulmonary. And so on.

Moreover, depending on the dynamics of a program, high workloads, political landscapes and hospitalist experience, hospitalists often generate much of the outsourcing for problems that, traditionally, internists would have handled on their own. Tachy? I’m busy; call cardiology. Nauseated? Well, so am I, thinking about those 15 patients I still have to see. Call GI.

Now, I do not mean to disparage the importance of consultants. I may very well, in a few years, be writing a different blog, one that bears witness to the continuing exodus of specialists from the hospital. The way things are going, I may practice long enough to hear the following: “The patient needs a craniotomy–quick, somebody stat page the hospitalist!”

So what to do? It seems like much of the cognitive scut could potentially be offloaded to physician extenders. I believe a number of programs are already doing this and that this trend will continue.

Perhaps CPOE will eventually make our lives easier, although right now I am not wholly convinced. Perhaps there are no ready solutions, and providing cognitive scut will simply be part of what it is to be a hospitalist. I doubt that prime time television dramas such as “House” or “ER” will ever show a physician filling out the MAR, and I’m sure that the less glamorous side of hospital medicine will persist. But the question remains: How much of the high-end, compelling and sexy decision-making will be ours as well?