Originally published October 23, 2014
By Joshua Allen-Dicker, MD, MPH
I am a young hospitalist who is 16 months into my role at an urban academic medical center. Unlike many of my more senior colleagues who found their way to hospital medicine by circumstance, luck, or as a second career path, I have been planning my career in hospital medicine since the beginning of my residency training. The things that drew me to hospital medicine as a trainee—its emphasis on problem-solving, strong communication skills, teamwork and leadership—are still what excite me each day as a young hospitalist. When friends, family and patients ask me about my job, I often tell them about these passions and describe what a “day in the life” looks like for me. While no two days are ever exactly the same in hospital medicine, the following is an account of a Wednesday I had last month.
I arrive at the large office I share with 9 other hospitalists. I log in to my computer and learn about the patients who were admitted to the hospital the night before, and any important events that occurred for the patients I cared for the day prior. With the help of our electronic medical record, I organize the list of fifteen patients I will be caring for, and review important laboratory, radiology and procedural reports. Three of my colleagues have also arrived and are similarly preparing for their day, an activity we call pre-rounding. As we work, we engage in an informal discussion of challenging cases—patients who may have a mystery illness, or a known illness that has been resistant to treatment. By reviewing cases, we learn from each other and are better prepared to start our day.
I begin seeing patients, who are all located on the same medical unit. By co-locating the physicians and the patients they care for, something we call geographic admitting, our hospitalist group has allowed for the creation of care teams. These care teams work together to ensure safe care during and after each patient’s hospital stay. My team today consists of:
- Several registered nurses
- Several nurse practitioners
- Two physicians
- A nurse manager
- A social worker
- A case manager.
I go from room to room, first visiting patients who may be especially sick, and then those who may be ready to leave the hospital that day. One patient admitted for treatment of a serious skin infection called cellulitis tells me about the fevers and chills she had overnight. I examine her, we discuss laboratory results and vital signs, and then she and I agree on a treatment plan together.
Another patient recovering from pneumonia excitedly tells me that he was able to walk down the hallway without any difficulty breathing. He knows that we have already prepared his discharge prescriptions and have made an appointment for him with his primary care doctor, and asks when he can be discharged.
Hospitalists in my group spend about half of our weeks on teams with resident physicians, and the other half on teams with nurse practitioners—today I am working with a team of nurse practitioners. I meet with them to discuss important medical events and review urgent issues that should be accomplished this morning, including facilitating the antibiotic change and discharge for the two patients I saw earlier.
I return to seeing patients, stopping in between rooms to write notes, consider important diagnostic dilemmas, coordinate with other physicians, and contact key family members.
At multidisciplinary rounds, the entire care team meets to discuss each patient on our unit. We review the reason the patient is in the hospital and how our team can best navigate the unique complexities of each situation to get the patient to their ideal health state. In addition to identifying a plan for medical treatment (e.g. new medications, changes to old medications, wound care, therapy/exercise), we often work directly with families, outpatient providers and insurance companies to ensure each person’s necessary outpatient support structure can be put into place. For half of the patients on the floor we actually bring the entire multidisciplinary team to the patient’s bedside all at once (instead of seeing them each individually after rounds).
As the work of hospitalists is so integral to day-to-day operations of hospitals and medical schools, many of us are also leaders in the areas of medical education, quality improvement, hospital administration and more. My colleague helps direct the internal medicine residency program. Another is the medical director for a hospital unit. Today is the monthly meeting of our Department’s Morbidity and Mortality Committee, which I co-chair. Our goal is to mitigate morbidity and reduce mortality in the hospital. We review patient cases, identify areas for health system improvement, and initiate projects to help providers give the highest quality of care possible.
I spend the afternoon working with my hospitalized patients. I do not have clinic hours at an off-site office, nor do I stray very far from the floor I work on—attributes that appeal to patients, families and hospital administrators. One very ill patient is being evaluated by several medical and surgical teams, who each have expertise in different aspects of the patient’s illness and may approach the same problem in different ways. I spend time speaking with each group of doctors, and then with the patient, to come up with the most appropriate treatment plan.
Another patient has fever, confusion and an unknown diagnosis. I review their chart, confirm their history with family members, and consult the literature to determine the necessary testing and treatment.
A third patient being treated for a new blood clot asks me about a blood test they saw online. We discuss the patient’s clinical progress, current evidence-based guidelines, and that occasionally some testing may be more harmful than helpful. We both agree that continuing the current treatment plan makes the most sense.
I remain in regular contact with the rest of my team. One nurse practitioner tells me about a patient who has developed new shortness of breath and is getting an x-ray and electrocardiogram. Another tells me about how they fielded a call from a concerned family member. Based on new information, we update our clinical plan. Over the last 15 years, it has become generally acknowledged that the provision of safe care depends on effective team work. No single physician can safely navigate the health system for all of their patients without strong skills in communication and help from a diverse group of providers. I rely on my team each day to help me fulfill my professional mission.
For patients who are being discharged, we contact their primary care physician via secure email, telephone, or fax. If we can provide outpatient physicians with the necessary information, we can all work together to keep the patient healthy and out of the hospital.
I attend a seminar hosted by several hospitalists about a new role our group will play helping surgeons and anesthesiologists to ensure patient safety before, during and after surgery—something known as perioperative care. It is exciting to see my colleagues take on new leadership roles within the hospital. I return to my office to complete my remaining work, including making sure the overnight physician is aware of important test results that may come back during the night. I pack up and head home to relax and prepare for the next day’s challenges.
As an early-career physician, hospital medicine offers me the opportunity for daily improvement as a compassionate clinician (I love working with patients) and leader (I love working with my teams). As hospitalists are key players in many health care operations, my job also allows me to explore my academic and clinical interests in improving care and developing the infrastructure for tomorrow’s health system. It is exciting to be part of the world’s fastest growing medical specialty!
Joshua Allen-Dicker is a hospitalist at Beth Israel Deaconess Medical Center and Instructor in Medicine at Harvard Medical School, both in Boston, Massachusetts. He wrote the above post while working as a hospitalist at Mount Sinai Hospital in New York, New York. He received his medical degree at New York University School of Medicine and obtained his Master of Public Health from Harvard School of Public Health. He completed both his internship and residency in internal medicine at Beth Israel Deaconess Medical Center. Josh sits on the Society of Hospital Medicine’s Physicians in Training Committee, is a compassionate health provider and quality improvement / systems enthusiast.