Social Worker declared my patient "medically unfit for d/c" today...

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DebDynamite

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I have a 90 YO patient I admitted to medicine floor for COPD exacerbation Monday night. This pleasant, hearing impaired, demented gentelman takes three meds: albuterol, one bp med and a home nebs. Oh, and a multi-vitamin.

When he came in, he wasn't moving air very well. My senior and I tuned him up with nebs (and ppx ABX). Totally afebrile, absolutely zero abnormal labs. He's ready to go home this AM, and I drop by the social worker's office at 0800 to let her know.

At 1000, she asks me if I've seen him yet today, did I listen to his lungs, etc..because his breath sounds are faint and he has some baseline wheezing, and you know he looks red and I "should realize that he's not ready to go home."

WTF?
Yeah, I'm at the va-h-spa. That is all.

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I have a 90 YO patient I admitted to medicine floor for COPD exacerbation Monday night. This pleasant, hearing impaired, demented gentelman takes three meds: albuterol, one bp med and a home nebs. Oh, and a multi-vitamin.

When he came in, he wasn't moving air very well. My senior and I tuned him up with nebs (and ppx ABX). Totally afebrile, absolutely zero abnormal labs. He's ready to go home this AM, and I drop my the social worker's office at 0800 to let her know.

At 1000, she asks me if I've seen him yet today, did I listen to his lungs, etc..because his breath sounds are faint and he has some baseline wheezing, and you know he looks red and I "should realize that he's not ready to go home."

WTF?
Yeah, I'm at the va-h-spa. That is all.

Intern learning point #1--when at a VAMC, there are any number of people whose opinions trump the credentials of the primary physician.
 
I didn't want to start anything, but she is a former nurse. I know she thinks she's looking out for her patients, and that I'm out to kill them. But seriously, let's get the otherwise kickin' it grandpa out of the petri- dish. Oh' no...maybe we should keep him in a VA bed until his lungs sound like he's 20.
What-ever.
I'm going to sit down and speak with her from now on about every single patient, I'm going to be so sickly happy I will make her think I have lost my mind.
 
Because bitter, pissed off people hate happy ones more than just about anything else. That is all.
 
I heard a social worker introduce himself as "Dr. _____ with social work" the other day in the ER. Looking at his badge, it said ____ _____, Ph.D. Not only is that lame (and a Ph.D is irrelevant in a clinical setting), it's misleading to patients. As I'm a medical student and a medical student's job is not to make waves or provoke confrontations, obviously I did not and would not say anything, but is it just me, or is that messed up?
 
I didn't want to start anything, but she is a former nurse. I know she thinks she's looking out for her patients, and that I'm out to kill them. But seriously, let's get the otherwise kickin' it grandpa out of the petri- dish. Oh' no...maybe we should keep him in a VA bed until his lungs sound like he's 20.
What-ever.
I'm going to sit down and speak with her from now on about every single patient, I'm going to be so sickly happy I will make her think I have lost my mind.

Or until he gets a nosocomial infection. Even better. When the social worker asks what happens, tell her it's all her fault because he'd be ok if he went home earlier. :D

I hate the VA.
 
Not worth fighting this battle in most cases (as a resident), particulary if it's just over an extra day or two.
It would be the opposite in a private hospital (patient pushed OTD before he's ready perhaps).
If you think the patient medically should go home today, would be best to let the attending fight it out with the social worker. Sometimes social work has a legitimate concern (i.e. patient can't safely take care of himself at home) but whether he is medically ready should be your attending's decision (in concert with your team), not the social worker's.
 
I heard a social worker introduce himself as "Dr. _____ with social work" the other day in the ER. Looking at his badge, it said ____ _____, Ph.D. Not only is that lame (and a Ph.D is irrelevant in a clinical setting), it's misleading to patients. As I'm a medical student and a medical student's job is not to make waves or provoke confrontations, obviously I did not and would not say anything, but is it just me, or is that messed up?

Well, assuming his PhD is appropriate to his field, i.e in counseling/clinical psych/social work, calling himself Dr. Whatever is just as appropriate as your introducing yourself as Dr. Whatever to your patients.
 
Well, assuming his PhD is appropriate to his field, i.e in counseling/clinical psych/social work, calling himself Dr. Whatever is just as appropriate as your introducing yourself as Dr. Whatever to your patients.

No, it is absolutely inappropriate for a PhD to introduce himself as "doctor" in a clinical setting. He should be politely told that doing so is not permitted, and if he argues or persists, he should be written up. If it continues to happen he needs to be fired.

This not a gray area. Non-physicians with doctoral degrees may not introduce themselves as doctors in clinical settings.
 
Flag your discharge orders. If anyone tries to over rule you just tell them you will document, "I have deemed this patient medically fit for discharge, however, nurse so-and-so disagrees with the physician's decision. As such, she can assume care of this patient. She will take responsibility for all medicolegal issues that arise from this point onward. Please refer all subsequent management decisions to her."

Send her a copy of that note, and have the nurses page her for any questions they have. These people always want to play doctor when it is convenient for them, but don't really want any true responsibility. See how many more times she gives you **** about your orders if you call her bluff.

-The Trifling Jester
 
Flag your discharge orders. If anyone tries to over rule you just tell them you will document, "I have deemed this patient medically fit for discharge, however, nurse so-and-so disagrees with the physician's decision. As such, she can assume care of this patient. She will take responsibility for all medicolegal issues that arise from this point onward. Please refer all subsequent management decisions to her."

Send her a copy of that note, and have the nurses page her for any questions they have. These people always want to play doctor when it is convenient for them, but don't really want any true responsibility. See how many more times she gives you **** about your orders if you call her bluff.

-The Trifling Jester

Well the problem with taking this approach is that the resident is not the truly responsible person for the patient's stay... it's the attending.

My advise to the OP... take it up with the attending, tell him how the social worker is prolonging the hospital stay of your patients and believe me all attendings care to reduce the hospital stays of their patients... even the dumb VA. Unfortunately, firing people in the VA is hard.
 
No, it is absolutely inappropriate for a PhD to introduce himself as "doctor" in a clinical setting. He should be politely told that doing so is not permitted, and if he argues or persists, he should be written up. If it continues to happen he needs to be fired.

This not a gray area. Non-physicians with doctoral degrees may not introduce themselves as doctors in clinical settings.

Guess you've never worked in PM & R where this is common.
 
While it's never a good idea to keep healthy people in the hospital for prolonged periods of time (because they will then proceed to get sick, guaranteed), sometimes you have to pick your battles.
 
Note my first post was three months ago. I was so sleep deprived and ticked off...My attending did in fact back me up, and the patient left the next day. The pt was 90 YO w/COPD. He had a home to go to, and while he didn't sound perfect at d/c, he sounded significantly better than when he arrived. Which, of course, the SW didn't have a clue about, as she only listened to him the morning he was to (originally) go home. She actually gave me a half- hearted apology the next day, mumbling something about knowing we shouldn't keep a 90 YO hospitalized too long, etc etc... I was already over it.

It was, after all the beginning of 2 months of wards, and she was my main go- to for SW. Not to mention the fact that the social workers at the VA (at least here) are incredibly over worked. What really sucked about it was the fact that I had to put up with it, and that he did increase his risk of, well, imminent death. Not to mention the VA food.

She pissed me off much, much worse six weeks later, however. I spent a TON of time on call with a sweet 'lil old lady whose husband was found to have prostatic ca mets everywhere on bone scan. She had his living will, poured over it with me- he clearly wanted DNR4/ comfort care only, and to go home to die. It actually stated in the living will, "Send me home to die"
(or something to this effect). Wife changed his code status, family all over the place crying, hanging out in room, and- of course, at the nurses station, and in the hallway I had to walk through to get my work done. It was Sunday when the code status was changed. Since I was post call Mon AM, I wrote SW a note explaining that pt wanted to go home to die ( he was 100% connected!), etc. Stopped fluids Sunday afternoon-evening, put comfort care orders....etc..

So, post- call Monday AM, I see SW in the hallway, ask her if she received my note, and she then informs me she did, but sending the pt home would be a bad idea, as she's "sure he won't survive the ride home and will die today."
THAT pissed me off, and I'm still mad. First, dying pt didn't get his wish. Second, I had to deal with family "how much longer doctor?" for THREE extra days- because he passed on Wednesday. I really hate the VA. UUuuggghhh!!!!!
 
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At our VA we would send the dying patient home if he wanted.
As long as he and family understand there is some risk of dying en route...which in actuality would probably not be high unless it's a 6 hour drive or something. Probably the social worker was worried that you didn't have hospice set up, etc. I think if his only issue was pain, etc. then he could go home with pain meds and home health nursing set up...we usually can get home health set up within a day or less, at our VA.
 
Its not uncommon for patients to die enroute, and medics know (usually) how to handle it (which is basically a show as the patient should be off monitors). Medics here will place them in bed, make them "comfortable", and then "recheck" the patient for clinical death, if actually passed away, call for funeral home of choice.

Personally I would either write up the MSW or have a discussion with them letting them know what they did was wrong, against a living will, and to be frank unacceptable. Frowny face for them!:(
 
At my hospital I have the opposite problem. On medicine I was frequently trying to justify to the nurse manager why the patient has to stay longer. I'm an intern and I saw patients before the attending and in my note if I write D/C home in the plan then the ball gets rolling quickly. If my attending sees the patient later and wants him to stay an extra day I have to write a note justifying the extra day. From now on I will write: "consider d/c home today. Will d/w team." Of course on any other service I would just d/c them because the attendings rarely even see them.
 
You know PM&R is a medical specialty, right?

Yes, having worked in a rehab hospital and opened up a rehab unit in a general hospital...

And it's also a nursing speciality.
 
At my hospital I have the opposite problem. On medicine I was frequently trying to justify to the nurse manager why the patient has to stay longer. I'm an intern and I saw patients before the attending and in my note if I write D/C home in the plan then the ball gets rolling quickly. If my attending sees the patient later and wants him to stay an extra day I have to write a note justifying the extra day. From now on I will write: "consider d/c home today. Will d/w team." Of course on any other service I would just d/c them because the attendings rarely even see them.

Or you can write something like "begin discharge planning." Many times I know the patient is probably ready to go home, but my attending has the final say, and sometimes they like to keep them an extra day. Or sometimes a circumstance arises which requires the patient to stay an extra day even when arrangements have all been made for the discharge.
 
Relax its the VA. Its like Alice through the Looking Glass down there.
 
Or you can write something like "begin discharge planning." Many times I know the patient is probably ready to go home, but my attending has the final say, and sometimes they like to keep them an extra day. Or sometimes a circumstance arises which requires the patient to stay an extra day even when arrangements have all been made for the discharge.

"Acute ride-o-penia". A common condition in the VAMC system...:rolleyes:
 
LOL at the wise old attending :)
I have seen this many times @VA.
 
Well, assuming his PhD is appropriate to his field, i.e in counseling/clinical psych/social work, calling himself Dr. Whatever is just as appropriate as your introducing yourself as Dr. Whatever to your patients.

There's a nurse practitioners website out there that has got a list of the states where it's ILLEGAL to call yourself doctor in a clinical setting unless you have an m.d., d.o., mbbs, etc...
 
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