7 minute read
Introduction—What’s the Problem?
Introduction
What’s the Problem?
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Dr. Hall exits the elevator to the third- oor intensive care unit (ICU), carefully balancing his co ee mug while trying to badge swipe the door and keep his computer bag from spilling its contents to the oor. Carole, the charge nurse for the day, nods hello as he perches his mug on the nurse’s station while sliding his computer bag under the desk. “Morning, Carole,” he says, motioning to the room across the corridor. “How is Mrs. Chaudhry today?”
Carole’s eyes widen. “Oh, she must be new.” One of the residents is sitting next to Carole, and Dr. Hall catches his eye while struggling to read his name badge. “Dr. Jackowitz,” he asks tentatively, “what can you tell me about patient Chaudhry?”
“Oh, I’m new today; I’ll have to check the computer.”
Turning around, Dr. Hall sees Tom saunter up the hall. Tom (Dr. Green) is the cardiology fellow assigned to the ICU this week. Hoping for some relief, Dr. Hall asks him about Mrs. Chaudhry. A blank stare tells him Dr. Green will be of little help this morning. Addressing Paula, the unit housekeeper, Dr. Hall rolls his eyes and mutters, “I guess I will be on my own again today,” knowing full well that Mrs. Chaudhry has been a patient on the unit for more than two days. Paula, who has worked there for een years, nods slightly and smiles. She appreciates that Dr. Hall always says hello when he passes her.
I could be Dr. Hall, a tenured, full professor of medicine and the attending physician in the intensive care unit at a large teaching hospital. I have lived this scenario almost daily. I arrive at 7:50 a.m. armed with a list of patients given to me by the computerized electronic health record (EHR) and look for my team, which includes multiple residents (doctors doing further hospital training, typically for three years), fellows (doctors doing subspecialty training for two to three years), medical or other professional students, nurses, aides, and unit clerks. Frustratingly, it is very likely I will be the only person consistently providing care for an extended period, perhaps seven to fourteen days. All the other team members will be present only intermittently. When rounds start at 8:00 in the morning, I do not know which residents or how many will be present. eir schedules and the work-hour rules mandate that they have to go home at a certain time, have a day o , or switch rotations midweek. e residents who are there may have never met their patients before.
In some cases, three di erent resident team members will be responsible for one patient during a twenty-four-hour period. If this sounds like shi work, you are correct. To make matters worse, the assignments are shu ed each morning to ensure equal numbers of patients are assigned to each resident. us, the resident who cared for Mrs. Chaudhry yesterday may be assigned to a di erent patient today.
Nursing assignments are likewise variable. While there may be a charge nurse, they typically rotate between doing this job and caring for patients at the same time. ey are not expected to know all the patients either, as their charge responsibilities relate mainly to sta ing and scheduling. Some sta nurses work eight-hour shi s, some twelve-hour shi s, some nights only, some ve-day weeks, some fourday weeks, and so on. Again, under the guise of being fair, nursing assignments are shu ed so that the same nurse does not have to care for the same very-ill patient for multiple days.
Unlike in years past, the unit clerks don’t actually work for your unit anymore. ey are part of a pool that helps multiple units, and they may not even be located near your unit! If a patient’s family
member calls when the computer is down, they will be unable even to tell the family member if the patient is still in the hospital.
Every day, I gird myself for what has become all too expected. When I ask how the patient is doing, four people head to the computer to see if there is any information. No one has actually talked to the patient yet. e resident may know the lab values drawn today but cannot tell me if they are di erent from yesterday. And so it goes, for een patients.
While there is a large “team” caring for the patients on paper, it is hardly a situation where I thrive as a provider. Frustration and fatigue accelerate throughout the week-long assignment, and my excitement about my chosen career languishes in the reality of the dysfunctional system. As the attending physician, I am legally responsible for the patient and directing their care. Other than me, there is little consistency in the care delivered to the patient. Most members of the “team” are just trying to get through their assigned shi as smoothly as possible. Except for me, the other players are expected only to work their shi ; another player will be assigned to relieve them a er that.
I have seen this same scenario play out in the smaller community hospitals I have worked in as well. Today, I may be assigned to cover hospital consult patients. When I arrive (again, with my computer list), I try in vain to nd anyone who might actually have information about the patient. O en, they were admitted overnight by a “nocturnist” or, in some cases, by a telemedicine provider. e hospitalist on-site today has not seen them. As in the teaching hospital, the nurses are on varied shi s, so they may not have handled that patient yet. Typically, the EHR notes are seven pages long (if you are lucky), with only one or two lines actually describing the medical decision-making at the time of admission. Since they are not required to be done for twenty-four hours, the history and physical (H&P) may not be written yet, so again, it falls to me to gure out what is wrong and how to treat the patient. I truly desire to get a handle on the issues, but I feel the tug of the other scheduled patients waiting for me in the clinic, not to mention
the other procedures I have to perform. And if that isn’t enough, the three new consults I’m there to see are expecting my attention!
Do these scenarios feel familiar to you? As a healthcare provider, have you experienced frustration and fatigue with an impersonal, administrative-heavy system where you don’t feel your opinion matters? Do you feel powerless to e ect change? I certainly have! But I now believe these issues can be addressed without signi cant expense or a major system overhaul!
It has taken me some time to write this book. In large part, this is because I have been mired in the problems, which I will outline, a ecting medical care delivery today. I have started and stopped on a number of occasions, o en feeling too tired or too frustrated to get my thoughts down on paper. Despite my frustrations, I’ve spent my adult professional life searching for answers to problems that have vexed my colleagues and me. is is not a book about physician burnout but about reempowering healthcare providers to do the things they love to do—care for patients, solve problems, in uence the delivery system, and have an enjoyable, empowering environment to work in. e message in this book will encourage physicians and other healthcare delivery professionals to create an environment and culture in which everyone can thrive by providing practical steps for positive change. As a colleague, it is also my intention to challenge healthcare administrators and system managers to appreciate the concepts outlined here and integrate them into how they design and manage delivery systems.
Part one will deal with how we got here. We will brie y review some of the major changes a ecting the healthcare delivery system over the past forty years and why they have not always improved the delivery of care to our patients. In part two, I’ll introduce ve fundamental areas that deserve special focus if we want to heal the system. I have called them T.E.A.C.H.: Teaming, Equity, Administration, Community, and Honor. We will explore how simple changes in each of these fundamental areas can result in the reempowerment of healthcare
providers. In Part ree, I will tell you about some key areas providers must personally work on if they want to become e ective leaders in the healthcare system. e nal part, part four, is my take on what it would look like if some of these changes were implemented—a futuristic, ctional scenario that I believe is easily attainable using suggestions from this book.
I trust that my words will resonate with you, the healthcare provider, to rejuvenate your heart and give you hope for a future where you can truly thrive as you practice medicine.
