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Keeping a grip on principles

July 2010

Say “medical ethics” around a hospitalist, and odds are the first thing that comes to mind is end-of-life care. But asking about code status, planning comfort and hospice care, and checking DNR orders are not the only areas in which hospitalists need to keep a grip on our principles.

Hospitalists are increasingly consulted by other specialists for “comprehensive patient care.” Sure, some of it is just to keep the surgeon from being awakened with requests for Tylenol orders. But once we’re on board we have as much responsibility as anybody else for the quality and appropriateness of the care being given.

Let’s take the preop clearance request you got last week from Dr. Bigbucks. He brings a lot of revenue into the hospital, so the administration wants him happy. And since the patient was a last-minute add-on when another elective procedure was canceled, an H&P needs to go on the chart in the next hour. 95% of the time there’s no problem and all of you are happy. But what if that 60-year-old executive admits that he takes his blood pressure meds only before a company physical, and he had to quit climbing stairs because his chest gets tight?

You write on the chart “Needs cardiac clearance”, call anesthesia and the surgery is cancelled. Two days later you get a call from Patient Relations about how mad Mr. Executive is, and Dr. Bigbucks is definitely chilly when you see him in the doctors’ lounge. A month later, your partners wonder why they aren’t getting as many preop calls as they used to. If the stress test on Mr. Executive comes out normal, you may wonder if you’re too hard to please.

One of the biggest temptations we hospitalists have is the urge to “get along by going along”: Stay out of disagreements, keep the consultants happy, don’t upset patients and families by making them wonder which of you is right. But sometimes the patient’s welfare depends on our willingness to speak up when something is going wrong.

That postoperative patient whose white cell count won’t go down even 5 days after surgery was supposed to have drained all the abscesses, the overdose in ICU who can’t be monitored for suicide attempts in a regular room, the guy whose TPN was ordered by another consultant who omitted something the patient really needs–these people are your responsibility too. So is the COPD patient who is already past his predicted length of stay and has a red sticker on the chart reminding you of that fact. Do you send him out a day early because you’re a “good team player,” or do you risk your LOS ranking by holding discharge until you can be sure his primary care doc will see him the next day?

As “cost-effective” care becomes a watchword, we are going to see more of these conflicts. Some threaten our income, others our popularity with other members of the medical staff, some just lead to annoying calls from the chief of medicine. But the pressure is there to minimize costs and maximize our own status.

If it hasn’t happened to you yet, be aware that it will in the near future: You are going to have to choose between the patient and the system (and your place in it). You will end up spending more time justifying your actions and smoothing ruffled feathers … and some of that may be in court. In the end, though, you will know whether you tried to do what was right for the patients in your care … or what was expedient for you.

If the patient is our first concern, isn’t his or her welfare worth an occasional argument? And if we allow other priorities to come first, what did we go into medicine for?