To Round Or Not To Round
I practice in a small Internal Medicine office of about 12 physicians, within a huge high-profile high-tech medical complex. We still take call and see our own inpatients, on a rotating call schedule. I will even sometimes admit my own patients and manage their care in-house when I am not on call. I have done this when I knew the patient very well and the issue was straightforward, such as healthy young-ish patients with kidney infections or new Type 1 diabetes; and also when I knew a patient needed extra loving care, and the on-call doc was a reknowned non-hand-holder.
Those times when I have covered my own patients and my outpatient practice at the same time, it was hairy. Really hairy. The days were very long and stressful. Even straightforward inpatient medical issues are, well, inpatient medical issues. Peope are admitted for a reason. They are sick. And they probably would have benefited from more attention than I could give. But they have always been really happy to see me.
The weeks I am on call and rounding for our whole practice, it gets hairy. Really hairy. I clear my morning schedule to round, but if the list is long or there is a very sick patient, the inpatient work can overflow into the afternoon of outpatients. Then, I have to excuse myself from a physical to answer a page about sudden desaturations, or the CT scan shows a PE, or “The patient wants to leave AMA,” or “The family is here and wants to talk to you”.
And more and more often, the medical stuff is new to me. I have a patient in-house now, in a critical care unit, who is so sick and so complicated; the tests, medications and even terminology being thrown around is all new since I trained. I have had to go quietly research what the hell is going on, to then be able to chat with the family with any authority. I had some input that was helpful for the critical care team, and I am sure they are thankful that the PCP is chatting with the family, so they don’t have to. But I am sure glad I am not responsible for her care right now, and she should be as well.
For some time now we’ve been considering not taking call, meaning not covering our own inpatients. We would use the hospitalist service. I am very torn about this. I feel like, hey, I trained in a brutally rough residency that was heavy on the care of the critically ill, I should be able to manage inpatients. It is thrilling to walk the hallowed halls of this hospital and think, Wow, I am caring for some very sick folks. It is fun and exciting to learn new medicine. And is is very rewarding to take care of my own patients when they have the most need.
But, it is harrowing/ stressful/ exhausting, and I wonder when I will make a mistake. I wonder when I will cause harm because I am not on call very often (about 5 weeks/ year) and thus not experienced enough, not up-to-date enough, not skilled enough. Inpatient care is complicated, and becoming more so.
We can still go see our patients when they are admitted, to let them know that we care, and to follow along with the team. Our hospital already offers a small reimbursement for those kinds of social visits, in the name of continuity. It’s small, but it represents a good faith effort… I have spent probably 4 hours total over the past 2 weeks with this very sick lady in critical care, and I have been reimbursed 35$ (the maximum). The reimbursement is very low, but the time spent has been worth it to me for many reasons.
So, should we bail on the inpatient care? I am fairly decided, and I think our practice is almost unanimous. We are giving it up to the hospitalists. But if we want to, we can still stay connected, and express that we care and are following along.
I wonder what patients think about this.