Anybody else's Hospitalists not admitting patients anymore?

[Apollyon]

You can respectfully disagree without turning personal or degrading an entire branch of medicine. Behave yourselves.

I would guess that it was strictly coincidence, but, I think it was 1976 (actually 1968), when Kingsley Amis wrote a "continuation novel" of James Bond, called "Colonel Sun"!

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[Siggy]

That reminds me of an IM resident when I was in residency. She would say "this pt is not appropriate for general internal medicine". You know who is not appropriate for general internal medicine? Peds and someone on-call to the OR. That's it.

Too sick, or doesn't need to be admitted? Tell me who is a shirking coward, and/or lazy, at that.

Active labor?
ICU patients in a hospital with an intensivist service and closed/pseudoclosed ICU?
Decompression sickness at a hospital without a chamber?

 

[Apollyon]

Active labor?
ICU patients in a hospital with an intensivist service and closed/pseudoclosed ICU?
Decompression sickness at a hospital without a chamber?

1 and 3 are very rare.
2 happened all the time at my rural hospital.

But you are just being oppositional.

 

[TooMuchResearch]

Some of the patients you mention here are borderline admission, others are admitable, others risky admissions . all have incomplete workup but that may be because you are attempting to succinctly give examples. Hospitalists justify being there by taking care of patients that undergo proper workup in the ED, usage of standardized disposition scores, etc. I could make a similar argument about most ED physicians I've worked with who basically function as revolving doors. You think Grandma has a bump in Cr from 1.5 to 2.3 because she's dehydrated? So why not do proper AKI workup and if suspecting prerenal, address reduced PO intake, give IV, recheck labs, and DC? And if you're wrong and AKI worsens? Is it the hospitalist's fault that you try to dump patients without convincing evidence for admission or discharge? If the CHF patient only needs slight diuresis, why admit? CHF exacerbation, you don't explain reason for exacerbation, and some reasons do require cardiology intevention. If not and you're so sure, double the oral dose and DC with close follow up. You don't want to take the risk but you expect hospitalists to take risks because you think they should. Transfer the SBO patient -- do you know how many times I've been refused a transfer after a patient has been admitted because ED didn't do proper workup? At times, refusal and delay of care resulted in significant morbidity and even mortality.

Just like a hospitalist can't force a patient down your throat or tell you how to treat your patients, you can't force them to treat patients they can't treat based on their knowledge, experience, and judgement, which are dissimilar to yours. You can do proper workups and apply standardized scores to make a strong case, which you haven't in any of your examples, but that's about it. Tertiary facilities have way more problems than lack of subspecialties -- aggressive admins, incapable supporting staff, and so on. Hospitalists aren't there as sacrificial lambs of other physicians or administers.

AKI workup, IV fluids, lab recheck, etc sounds like an admission to me...

 

[TooMuchResearch]

Dingus? lol. Severe AKI? Likely prerenal etiology? urine electrolytes and US? LOL are you even a doctor!? You don't even know how to work up AKI appropriately. Even if a doctor, obviously not a very good one. You see, even though a hospitalist can tell you how to do proper ED workup of AKI, you think you can tell a hospitalist how to do his work. That is the problem. But hey, no worries, it's the hospitalists' fault even though you have no idea what you're talking about.

Besides, it doesn't matter what you think. That's what books and guidelines are for, and your lack of knowledge does not = hospitalists don't know what they're doing and should do as I say because I have admin back. Hospitalist do their job by telling you disposition of patient, don't they!? Is it their job to care for patients they shouldn't be caring for because you think otherwise!? Do ED physicians define Hospitalist jobs!? Unfortunately, bud, the same rules and laws that define your physician autonomy also define them lower intellect (at least from your point of view) hospitalists who need your help with their job. If hospitalists can save "grandma with severe AKI" a hefty bill because you and admin have selfish reasons or at best, are unprofessional, they will lawfully do so. Obviously, if hospitalist and ED both mature, professional, at least some ethical, they will have a conversation and make their points, but you don't get to one-sidedly force a physician patient relationship on another physician, kapish? LOL. look how hard it is for you to accept hospitalists as physician who have right to refuse such a relationship. Bet you don't have same issue with other specialties, now do you? Let's just call it what it is -- you think you're stronger, better, and in general superior to hospitalists so you expect them to do what you say, regardless of patient safety, appropriateness, blah blah blah. Don't beat around the bush, bud.

In conclusion, Do YOUR job buddy, perform basic ED screens and workups, do the HEART scores, stop taking d-dimers on every patient that comes in with shortness of breath and tachycardia, don't call for admission of radiologic pneumonia of a patient who just finished pneumonia treatment, etc. You know, do medicine... and meanwhile, stay out hospitalists' hair regardless of how superior you think you are. In reality, you're not. Hospitalists (inpatient doctors) don't come to ED and tell ED physician how to manage their patients in ED. Show same professional courtesy and maturity even if it costs you a couple of phone calls and a little less nap time.

Yeah I don't work it up beyond that. Not our job. Although I've looked through enough discharge summaries to know that most hospitalists also don't think it's their job. I block this person now.

 

[HemeOncHopeful19]

That reminds me of an IM resident when I was in residency. She would say "this pt is not appropriate for general internal medicine". You know who is not appropriate for general internal medicine? Peds

I am still to this day pissed about the time Peds tried to get me to go consult on a 14 year old who was pregnant with an Asthma exacerbation because she was "functionally an adult" and then later tried to claim she was an "emancipated minor due to being pregnant (or maybe she was post-delivery I forget), and therefore an adult" as a reason she should be an IM patient (I am not joking)

Edit: Our IM dept ended up sending over a competent Med/Peds resident who really wished he had just done IM

I also once had Ortho try to get me to admit a patient because they were "old" despite taking no meds and having no comorbidities "well can't you order some tests and find some meds they should be on?"

 

[Splenda88]

I remember vividly as a PGY2 about a consult of a young 18-20-yr old pregnant patient with a bad asthma exacerbation on an OB floor. She was very close to delivery date, and you can see the horror in the nurses' face when I came to see patient.

I was rotating at a small hospital (~300 beds) outside of our system.

I did my things; I stayed on that floor for a good hour and gave the charge nurse my personal phone # and told her to call me directly if she thinks the patient is not turning the corner in a couple of hours. I did not have home access to their EMR. I did not receive a call at all from the charge nurse.

The next morning, when I showed up to see the patient, all the nurses were clapping because patient was doing so much better.

That was the first time I truly felt good about being a doc. Needless to say that I could have made myself a nice cute RN gf that was > 10 yrs younger than I on that floor if I was not married. 🙂