I've been working as a hospitalist for two weeks now, and I think I've settled in pretty well. During the first week I bumped my cap up from 5 to 12, and more recently bumped it up to 14. The most number of patients I've had to see so far on any given day is 12, but even that was manageable. The real challenge is going to be the weekend, when each hospitalist has to see 25-30 patients; I'm guessing I'll be at the hospital until 5 pm. The other hospitalists in the group have been very helpful and supportive in giving advice or providing me with contact information for the various specialists in the hospital. Probably one of the best parts of being an attending is that no specialist will give me crap for a consult. A surg-onc didn't mind the prospect of doing a Whipple on a Saturday when I told him about a pt with resectable ampullary CA. I had to consult one heme-onc attending twice in one day because her number was the only one I had, causing her to stay at the hospital until 7-8 pm, but when I met her in person she was gracious and thanked me for the consults. I was giving her business, after all; one of the consults was for a newly diagnosed colon CA.
One of the oncologists commented that being a hospitalist at SAMC is not all that different from residency, and in ways she is right. Because we don't do the 7-on, 7-off schedule, we can leave the hospital as soon as our work is done on non-call days (for me, that's probably around 2 pm for 10 pts). That means a certain number of people have to stay later at the hospital each day to take call and do admissions. There's two people on call between 12-5 pm, two people between 5-10 pm, and then a designated night float who does all overnight admissions. On average I take call twice a week. Some people will even volunteer to do extra calls so that they get more patients (apparently H&P's bring in the most money), a concept that's still foreign to me. I only need to support myself, and was able to do so on a resident's salary, so right now I don't feel the urge to work extra shifts for extra money. Of course, if one of the partners becomes ill and needs someone to cover their shift, I'll volunteer as long as I don't have to do two calls in a row.
This sort of schedule works well for me because I like leaving the hospital as soon as my work is done (I always hated the 7am - 7pm shifts and vice versa when doing triage/MAR in residency), and I wouldn't know what to do with myself if I had seven days off. I suppose I could moonlight if I wanted to; one of the hospitalists said that he used to work at a 7-on, 7-off hospital and would moonlight on his weeks off for extra money. Plus, at least in Austin, there's a whole lot you can do for your week off. Personally I think I'd get burned out too quickly if I had to work seven 12-hr shifts in a row that involved both admitting new patients and taking care of old ones. At least now I don't have to admit everyday.
My two week adjustment period is over. Starting tomorrow, I'll be working almost every other weekend, taking call 2-3 times a week, and seeing well more than 10 pts a day (which I've just become comfortable with). Weekends have become more precious than ever. I never did like working black weekends in residency, but that's part of the package in this hospital. As long as I make my golden weekends worthwhile, then I hope things will be okay.
Sunday, September 30, 2012
Tuesday, September 18, 2012
First Day of Work: Plagued by Doubts
Yesterday was supposed to be my first day on the job, but since I wasn't assigned a user name for computer log-ins until the morning (apparently someone forgot to sign my credentialing papers on Friday that would have allowed me to start work on time), I had an extra afternoon off. My morning, instead, was spent familiarizing myself with the layout of patient charts and learning how to use the EMR at this hospital. Some of the attendings suggested that I could shadow someone for the day, but I respectfully declined. These guys had patients to see; I didn't want to take away from that time by having them babysit me.
Back in February I accepted a contract from a hospitalist group that works in various hospitals around the city; I would be spending most of my time in one particular hospital, the SAMC. The SAMC has only 200 beds, but our group cares for the majority of the patients. There are about 15-16 hospitalists at SAMC, and each one sees 12-15 patients daily on average. Fortunately for me, the "pod leader" of the hospitalists was going to start me off with 5 patients, and no call for the rest of September until I learn to do things around the hospital. That's more than kind. One of the hospitalists (who shares my last name) made a point of taking me to different nursing stations and introducing me to the nurses, for my sake as well as his (i.e. please specify which Dr. ____ you need, the male or the female). Most of the nurses knew of my arrival and were both welcoming and happy to see me. "You guys just keep hiring!" one charge nurse commented; before I arrived, another woman started in July, and several people started working in February.
After 2.5 months of "freedom" from medicine (1.5 of which was devoted to boards), I was eager to get back to being a doctor again. Five patients doesn't sound like a lot, but on the first day, I probably averaged 45-60 minutes per patient because I wanted to be thorough. The safety net I had as a resident is gone; there is no attending to tell me what to do because I am the attending now. Sure, I can ask my more experienced colleagues for help, but I need to show them I can stand on my own two feet. Fortunately I was given relatively easy cases (nothing in the MICU): three chest pain rule-outs (one went to cath, two got stress tests), one rhabdo, and one N/V with elevated troponins.
Even though I was pretty sure I knew how to take care of my patients, even after I went home, a lot of things nagged at me. My rhabdo guy also presented with sky-high LFTs; was it safe to attribute the LFTs only to the rhabdo when the RUQ U/S just showed a fatty liver? At the hospital I was able to justify not getting GI involved; at home, I wonder if I am doing the right thing. I also noticed his chloride was creeping up, possibly due to all the NaCl I'm giving him, but how high is too high? One attending suggested I treat him with a bicarb drip because his CK exceeded 50,000, but his bicarb and creatinine were normal and CK was falling with fluids so I chose not to do so. Then one of the nephrologists called my cell expressing concern that her patient was having worsening back pain and may need an MRI (despite negative films). A cardiologist paged me at 6 pm to let me know one of my chest pains had a negative stress test; had this been hours earlier, I might have discharged her. Another chest pain just needed his cardiologist's input as to whether he can go home; I asked the nurse to call me once they had an answer; they never did. I just know I'll feel really bad tomorrow morning if I find that one of the on-call partners had to discharge my patient for me.
This is probably the toughest part of being a brand new hospitalist fresh out of residency: even after I go home, I find myself worrying about whether or not I did the right thing for my patients. Some of this may be attributed to lack of confidence; I was never the smartest resident in my class, but I tried to make up for it with being hardworking and responsible. I imagine it'll take some time before I'm truly comfortable being a full-time hospitalist, but for now, I'm willing to take things day by day.
Back in February I accepted a contract from a hospitalist group that works in various hospitals around the city; I would be spending most of my time in one particular hospital, the SAMC. The SAMC has only 200 beds, but our group cares for the majority of the patients. There are about 15-16 hospitalists at SAMC, and each one sees 12-15 patients daily on average. Fortunately for me, the "pod leader" of the hospitalists was going to start me off with 5 patients, and no call for the rest of September until I learn to do things around the hospital. That's more than kind. One of the hospitalists (who shares my last name) made a point of taking me to different nursing stations and introducing me to the nurses, for my sake as well as his (i.e. please specify which Dr. ____ you need, the male or the female). Most of the nurses knew of my arrival and were both welcoming and happy to see me. "You guys just keep hiring!" one charge nurse commented; before I arrived, another woman started in July, and several people started working in February.
After 2.5 months of "freedom" from medicine (1.5 of which was devoted to boards), I was eager to get back to being a doctor again. Five patients doesn't sound like a lot, but on the first day, I probably averaged 45-60 minutes per patient because I wanted to be thorough. The safety net I had as a resident is gone; there is no attending to tell me what to do because I am the attending now. Sure, I can ask my more experienced colleagues for help, but I need to show them I can stand on my own two feet. Fortunately I was given relatively easy cases (nothing in the MICU): three chest pain rule-outs (one went to cath, two got stress tests), one rhabdo, and one N/V with elevated troponins.
Even though I was pretty sure I knew how to take care of my patients, even after I went home, a lot of things nagged at me. My rhabdo guy also presented with sky-high LFTs; was it safe to attribute the LFTs only to the rhabdo when the RUQ U/S just showed a fatty liver? At the hospital I was able to justify not getting GI involved; at home, I wonder if I am doing the right thing. I also noticed his chloride was creeping up, possibly due to all the NaCl I'm giving him, but how high is too high? One attending suggested I treat him with a bicarb drip because his CK exceeded 50,000, but his bicarb and creatinine were normal and CK was falling with fluids so I chose not to do so. Then one of the nephrologists called my cell expressing concern that her patient was having worsening back pain and may need an MRI (despite negative films). A cardiologist paged me at 6 pm to let me know one of my chest pains had a negative stress test; had this been hours earlier, I might have discharged her. Another chest pain just needed his cardiologist's input as to whether he can go home; I asked the nurse to call me once they had an answer; they never did. I just know I'll feel really bad tomorrow morning if I find that one of the on-call partners had to discharge my patient for me.
This is probably the toughest part of being a brand new hospitalist fresh out of residency: even after I go home, I find myself worrying about whether or not I did the right thing for my patients. Some of this may be attributed to lack of confidence; I was never the smartest resident in my class, but I tried to make up for it with being hardworking and responsible. I imagine it'll take some time before I'm truly comfortable being a full-time hospitalist, but for now, I'm willing to take things day by day.
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