Why this primary care physician still rounds at the hospital

By | December 27, 2019

I have been fortunate in that I have not had to hospitalize any patients in the past four weeks.  This means I have an extra 60 minutes or more to prepare for the workday in my office. The streak ended this weekend when my associate, taking his rotation of being on call, hospitalized one of my patients with pneumonia.

In many cases, pneumonia is treated as an outpatient. You receive an antibiotic and cough medicine and stay at home, rest, hydrate, and recuperate.  In this case, the patient has had multiple lung surgeries to save her life from cancer, and she is left with much less pulmonary reserve than most.  She was coughing with a productive cough for several days as she moved from one home to her future residence while her husband, who usually watches after her, was away. By Sunday morning, it hurt to breathe, and she was exhausted. She called and spoke to my associate, who suggested she meet him in the hospital emergency room.

Being an anxious and nervous individual, she called her cardiologist next, repeated the story, and he wholeheartedly concurred with the decision.  In the ER, her X-ray showed multiple areas of pneumonia, and her elevated white blood cell count and temperature (which she was not aware of) confirmed the problem.  Blood and sputum cultures were obtained; antibiotics guided by an infectious disease specialist were begun.  Surprisingly and fortunately, she was not wheezing, her lungs sounded better than on many visits, and she did not feel particularly ill compared to past encounters of this nature.

She was moved to a private isolation room where hospital routines and protocols took over and created nothing but anxiety and concern.  She had been on a low dose of corticosteroids as an outpatient, and because her body was stressed, she needed a higher stress dosage short term.  It was ordered on the computer system to be given all at once after a meal, but the pharmacy protocol called for multiple dosages, and this conflict resulted in her getting half the dosage ordered.

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When the patient noticed the difference in administration, she complained to her nurse.  However, no one had been notified.  The infectious disease specialist ordered an extra dosage of intravenous antibiotics for the evening of her arrival. The pharmacist noted that a dosage of this long-acting medication had been administered earlier in the day and canceled the order for the evening dosage without anyone calling the ID doctor or me as the attending physician. The patient objected but was overruled by nursing.

The patient was receiving a respiratory treatment with a medication that speeds up her heart rate greatly.  She normally takes a drug to prevent rapid heartbeats called a beta-blocker. This was ordered for her but not given because the patient’s blood pressure was considered “too low.”  The problem is that the patient is a small thin woman, and her blood pressure is always this low. She has taken this medication for years at this dosage with no ill effects.

When the covering physician placed the order for these medications, the parameters for withholding the drug due to slow pulse or low blood pressure were not presented for his consideration. Once again, a medication was held, the patient was aware of it, and no one called her attending physician or cardiologist to discuss it. This made the patient even more anxious and upset.

Since early spring 2019, the physicians’ parking lot has been closed while the facility builds a new parking lot. They have the doctors parking in a much more distant location, about 2,500 steps away from the main entrance.  It takes an extra 10 minutes to reach the entrance in and 10 minutes, leaving now to get to your car and then leave. On a hot, humid South Florida summer-like day, you need to shower by the time you reach the air-conditioned main entrance.

Upon entering the building with our new corporate ID cards, it takes another five minutes or longer to reach the patient floor if the elevator is free. From there, you walk to the nursing station and try and find an open and functioning computer terminal.  In past years, when I entered the nursing and administrative section of the patient floors, the nurses and aides would say good morning and greet me by name. The patient’s paper chart was handed to me, and a nurse would accompany me to the bedside to discuss the day’s plan, review the patient’s progress, and reconcile the medications.

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In today’s hospital no one looks up from their screen, rarely does someone say hello and I would not be surprised if I showed up in a Halloween Costume of Freddy Kruger if anyone would even notice.

Every item of information is now on the computer. Once you obtain an open workstation, it takes several minutes to log in using multiple security rituals to finally find the patient’s chart.   If by chance your patient ran a fever and you have to complete the “sepsis protocol,” or if you decided not to start the patient on a drug to prevent blood clots from developing, you can add another five minutes just to remove these from your screen and actually get to your patient’ data.

After completing this, I walk to the patient’s room to find my teary-eyed patient complaining about being awakened for blood drawing and how rough and inconsiderate the phlebotomist was. She is upset about the missed medications and alterations of her home medication schedule and her fears about how this would affect her and the plan to get her home.   The examination takes a few minutes and confirms that she is improving and moving towards going home soon.   I explain to the patient what I think should occur and get her input and approval and then search for her nurse to review it verbally. It’s then back to the workstation to find a free computer, so I may enter the orders I just reviewed with nursing.  A bedside computer station with a nurse present would cut 10 to 15 minutes off the process, but they are not available yet.  My iPad has access to the system at the bedside, but the smaller screen makes entering orders difficult and offsets the convenience of a bedside computer.

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As I enter my patient’s room, I see her face covered in tears.  She brightens up with a smile as I walk in and then begins to tell me about everything troubling her. Initially, most of my time is just spent listening and observing.  I listen intently to her concerns and fears and assure her she is moving towards a morning discharge.  I then phone her husband with a progress report.

It’s five flights of stairs down to the main floor. I notice that a helium balloon bouncing against the ceiling above my reach is still present for the third day.  When I leave the building after using my identification card once more to open the exit door, I trudge 2500 feet through the outdoor construction area back to the car to begin the now 20-minute ride to the office to see my morning patients.

I now understand why many of my colleagues only see patients in their offices. The sheer bureaucratic, protocol-driven nature of the hospital process makes caring for a patient infinitely more dangerous, more time consuming, and more inefficient.   I cannot wait for this patient to be well enough to be discharged before another hospital protocol disrupts her recovery and makes her ill.

The inconvenience of coming to the hospital is exhausting.  Although, the look on a sick patient’s face when a familiar caregiver arrives to take charge and help them through the rough spots is still worth the trouble.

Steven Reznick is an internal medicine physician and can be reached at Boca Raton Concierge Doctor.

Image credit: Shutterstock.com