Notes on Shadowing a Hospitalist
humaninvariant.substack.com
humaninvariant.substack.com
Case in point: requiring everyone in the operating room to say their name, specialty and reason for the operation (and their part in it).
You might ask why the above is necessary?
Well:
- everyone is wearing a mask, cap and possibly glasses which makes them hard to recognize
- the patient is often draped in such a way that you can't tell who they are
- many Operating Rooms(ORs) look the same
- there are apparently COUNTLESS stories of medical personnel going into the wrong OR and not realizing until the surgery has started
Another fascinating point about checklists since the OP article mentions doctors vs nurses: checklists give nurses the power to challenge doctors. e.g. "Dr, I believe the next step on the checklist we agreed on is to do X".
If you have no checklist, the Dr can just say "No, we don't need that, I know what I'm doing. Shut up, Nurse!" (this is a real example from the book btw).
He also has an article comparing the Cheesecake Factory to health care that I also highly recommend [1]
If you liked that, here's my own recommendation for something he's written: https://www.newyorker.com/magazine/2010/08/02/letting-go-2
Why? Well she definitely didn’t want to ever make the mistake of operating on the wrong arm, and if I’m anaethsetised it’s not like she couldn ask me while the procedure was underway.
[1] Susan Alexander- She’s absolutely amazing. If you have shoulder problems and live in the UK I would strongly recommend.
What I suggest is that if you have a friend or relative visiting you, they should bring a "flip chart" -- the old fashioned 2 x 3 foot pad of paper -- and write down in huge letters the most important details of the case. Ask the doctor to help you fill it in.
I spent most of my life perceiving comedy to be one of the less serious art forms. “You can make a beloved film but won’t win a Best Picture award” kind of less serious.
But I read sections like this one, and I experience the use of comedy for community-building and healing and discussing politics safely. And I’m growing a belief that it’s the highest, purest, most honest form of communication we have as a species.
We want to make death less taboo, but what we really need is to make joking about death less taboo.
Over the years I hear a lot of their pain points, and EMR's are consistently very painful for my boomer parents who are not tech savvy (my understanding is that it's not an age thing, though).
I have personal experience with pt. 8: Doctors know who's good, they just won't tell you. When I had a meniscectomy with poor results, none of the orthopedists I visited after the surgery would comment even lightly on the appropriateness of that procedure given my symptoms and MRI. This isn't different to other professions, where you generally have nothing to gain from badmouthing colleagues, but its incredibly painful that thousands of people are prevented from good care because of this meritocratic breakdown.
As a totally separate point-- this format of shadowing notes in incredibly compelling! I've been shadowing chemistry and biology wet-labs lately, and I wonder if making similar writeups would be interesting to others?
Once, in a situation when we really wanted an opinion from a nurse who wouldn't give one, we finally asked, "If it was your daughter, what would you do?" With no hesitation, she told us exactly what she would do. She just couldn't tell us what we should do.
That phrasing has proven to be useful a time or two since then...
So I said, "Well, leaving aside recommendations, who do -you- use as your auto insurer?"
> But all hospitalists are paid under the same schedule (based on years of experience), meaning that the high-agency hospitalist is getting paid the same as their counterparts. Greater intrinsic motivation and competence are not explicitly rewarded.
I find it very hard to believe that it’s possible to measure “greater intrinsic motivation and competence” objectively here (and for GPs as well, basically any profession with high variety in the Stafford Beer sense), so explicitly rewarding that seems fraught with Goodhart-style problems.
They also mentioned surgeons being "top of their list" - what list? Surgery success rates? That's widely understood to be a problematic measure. Surgeons can boost their success rate by only doing easy operations. Conversely, a surgeon who operates on the most at-risk patients will get a lower success rate because the patients' chances of a good outcome were bad no matter what. Regardless of how good the surgeon actually is, which might be impossible to measure objectively.
You usually combine a minimize days in hospital goal with a minimize readmittance goal. And combine with supervision to ensure low readmittance isn't due to patients being admitted to the morgue instead. Ideally, some longer term measure of patient outcomes. But as you mentioned, you also need to account for the mix of patients.
Everything comes down to the implementation at the end of the day. We've had people come into our Meditech 6.x shop from other shops (Cerner, CPSI, MAGIC installs) and comment how much Meditech was an upgrade, and I'd see Epic users complaining about the downgrade all the same.
The entire region's gone up to Epic now thanks to mergers from larger systems, and every site that had everything prior now (especially that crummy little CPSI system) agrees that Epic is now the best thing since sliced bread.
Coming into it though finding out just how much lives in the system... wow. I was amused to see that HR very much lives alongside nurses in the same system (Meditech's HR modules... and an employee portal that quoted copyrights from 1995 from Photodisc!).
To convert this context from medicalese to technese - when a hospital (system) buys an EMR (medical record system), it's like purchasing a very fancy version of "vim" or "emacs"
As all of you know, vanilla vim or emacs can be a very different experience from a polished and tuned up config file version.
So doctors are at the whims of their hospitals high (or often low) quality vim/emacs config, or .rc file of your choice - that's what "implementation" means
Some systems like Kaiser are famous for having super duper special high quality epic configuration, making epic famous for quality, though implementations (vimrc) in other hospitals, most other hospitals, is shite
https://www.hospitalmedicine.org/about-shm/what-is-a-hospita...
Very few general medicine doctors see clinic patients and hospital patients these days. In subspecialties, it's still common to do both, but we've started to see OB hospitalists, and it's not unheard of for surgeons who have aged out of doing surgery (malpractice insurance becomes onerous to obtain in procedural specialties after age 70) to continue working in their former practice as clinic-only doctors, which allows the younger ones to stay in the OR (which is where the surgeon makes almost all of their money) rather than run back to clinic fifteen minutes down the road to see routine follow-ups.
They aren't traditional specialists but for pay / prestige / political reasons they are recognised as specialists (to recognise their level of training and experience and the importance of their role).
Another aspect is automation development. Particularly for people who are supposed to be writing tools for another profession, it's worthwhile spending time getting some notes like thing.