* * Anonymous Doc

Monday, January 17, 2011

I understand the comments on the previous post. I should have been clearer, maybe, so that it would be more obvious that the problem is the system, not the ethics of the doctors. Even if the patient cap wasn't an issue, we would still save the discharges until the end of the day. Because discharges take time, and every minute we spend on a discharge is a minute we can't spend on patients who have active problems we need to deal with. The priority is the sick patients who need our help, not the patients waiting to go home. To stop in the middle of the day, when there are still things on our list, to discharge someone is a poor use of our time. There are only so many things we can do at once.

Similarly, every minute we spend processing an admit is a minute we can't spend running our list and dealing with what we have to deal with. If I'm called at 2:00 to process a new admit, it means everything on the patients I already have on my list gets pushed. We're simply never sitting around doing nothing. It's not a matter of avoiding work. We are always doing something. We are always busy. We are always left with less time than we need. And any of us would rather prioritize the patients we're already dealing with and trying to treat over the new admissions that are waiting to be processed. Because we already know the patients on our team, and they need us. The new admits can be processed by anybody.

The night team ought to process the new admits. They don't come in with a list of things to do for the current patients. They come in with a blank list. We work the whole day trying to get as much done as we can to get out at a reasonable hour and get a little bit of sleep before coming back in to do it all over again. If we have nothing to do, sure, give me a new admit. But otherwise we are busy. And if we have to spend the whole day processing new people, the old people will crash and burn. I need to protect my people. My patients, and my interns. So I will do everything I can to avoid new admits if I can push them off, because I don't want to deal with all of my patients dying on the floor because I was distracted.

There ain't enough people. That's the problem. We have an unlimited amount of work. No one's being lazy. We're just trying to manage our day and not get overwhelmed and sacrifice care. This is vastly different from the ethical problem of buying your way into medical school. Or I'm just delusional.

Oh, and I probably overstated how much control we have anyway. Even if we process the discharge, they're usually there for hours waiting for social work or pharmacy or nursing or someone to come pick them up (that's always a fun one). They're just as busy as we are, and they're just as likely to have sixteen other things to do that take priority over a discharge. So it's not like we're really in control.

But I won't pretend I'm backtracking from the post. None of us want new admits if we can push them off to the next shift. Not the doctors, not the nurses, no one. We have too much to do already with the patients we have, and we don't want to be at work 24 hours a day. And we shouldn't be.


  1. Incidentally, at our hospital we have a hospitalist-only team (no residents, maybe a med student or two) that takes patients once the residents have capped. I'd imagine that's how it is at many places.

    And of course, the hospitalists don't have a cap...

  2. I definitely blame the system: it shouldn't be possible even for a purposely lazy person to put off admitting someone for over two hours. ERs have to treat people not based on ability to pay, right? Well, that's how you get people lining up to wait instead of a sufficiently staffed system. Just like the Soviet Union. (That and the government restrictions on how many doctors we have and what nurses can help with.)

    I'm not sure I entirely buy the "we're too busy" argument. I can see in my factory how different people make the same job take all day or three hours a day, and how the speed of my line makes me prepare for changeovers in fifteen minutes that would take me an hour to get ready for with no time pressure. Busyness is about knowing what's worth doing as much as work load. (I do way too many details myself and always have trouble getting out on time.)

  3. I just wanted to say a quick I appreciate your honesty. There are a lot of Ugly Truths in medicine and I'm always glad when someone has the balls to talk about them honestly and openly even though in any sort of forum, maybe, especially blogging, there are likely to be reprisals.

    I think many of the Ugly Truths stem from balancing the often overwhelming workload. It is a mentally, emotionally, and physically draining but ultimately (for most, hopefully anyway) rewarding job. And you DO have to strike a balance between doing the best you can to meet your patient's needs while preserving your own sanity. (Sometimes, for some of us, it helps to blog about it.) I understand (I think I do anyway) that is what you're talking about here Anon Doc.

    You are not alone.

    I wish you (and all of us) the best of luck continuing to fight the good fight!

  4. I should point out to the previous commenter that, while ER are required to treat people regardless of their ability to pay, the order that they treat them is determined by availability and severity. So, if you've sat in the ER for 18 hours watching others get taken care of before you, rest assured it has nothing to do with your capacity for payment. The other entrance often brings in patients that are far worse shape than you are.

  5. @Noumenon - Hospitals are not factory lines. On a factory line, you know when new items arrive, and you have closed processes that do just what they are supposed to do. It's a machinery.

    Hospitals do not know when the next patient comes in, how urgent each case is going to be, how many and what resources are required to treat the patient, or how long it will take even to diagnose the patient. Because each patient is different.

    However, there is certainly a case for hospitals to think Lean processes.