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A Day in the Life of a Hospitalist
Itís a relatively quiet Wednesday morning on 5 South, home to Northwest Hospital & Medical Centerís medical care unit. A few heart monitors beep. Nurses at the end of their shifts brief those coming in for the next. A ringing phone interrupts the calm and then falls silent.
This is where the hospitalists of Northwest Hospitalís inpatient team start their days.
The inpatient team is a group of 15 board-certified internists who provide care exclusively to hospitalized patients. On this particular morning, hospitalists Dr. Santiago Neme and Dr. Michael Fujimoto take a moment to collect themselves in the team charting room, an alcove behind the nursesí station. Here, the doctors review their caseloads, and prepare for the day ahead.
Each doctor prints a list of all the patients he needs to see. While reviewing his list, Dr. Neme pops a mint into his mouth, something he will do periodically during his rounds. Then, he begins to markup the list using a puzzling system of arrows, boxes, slash marks and circles.
"The arrows tell me which patients may be ready for discharge. Open boxes tell me I have something to do for that patient," he says. He draws a square next to the name of a patient needing a nutritional consult, a visual reminder for a task yet to be completed. "Once the tasks are complete, I can put a check through the boxes."
The doctors take off on rounds, starting with the sickest patients first, then moving on to patients in need of immediate discharge and, finally, checking on the patients who are most stable.
Never the Same Twice
In a hospital, every day is different and for Dr. Neme, today is no exception. He hasnít had a cup of coffee. He didnít eat breakfast Ė a meal he routinely skips. He hasnít finished checking his email or reviewed notes on the first patients he intended to see today. Instead, he answers a page from the emergency department and ends up admitting an 83-year-old woman who has suffered a stroke. In between documenting orders in the womanís chart, answering pages and coordinating her care, Dr. Neme makes phone calls to contact the womanís primary care provider and find her immediate family members.
Not long ago, primary care practitioners admitted their patients to the hospital and controlled their treatment during their hospital stay. In hospital-based medicine, a fairly new practice, hospitalists share the care of hospitalized patients with the patientís other doctors, who may not always be able to come to the hospital to direct and monitor their care.
Dr. Neme considers the journey from admission to discharge to be made up of a few basic steps Ė meet the patient, get to know him or her, assess his or her acute medical needs, establish a plan, implement the treatment, see a positive outcome and prepare the patient for discharge.
"Discharge planning begins soon after patients are admitted," he explains. "The end goal is always to set them on the right pathway to recovery and have them leave the hospital with a personalized follow-up plan."
Coming up with the right plan for each person means spending enough time with patients to get to know them. The doctors begin by asking questions: How are you feeling? What has happened since I last saw you? What did you eat? Have you been able to walk? How is the pain? Have you talked to your family? What do they say? Do you need anything? What is concerning you? What questions do you have for me? In many cases, the answers to these questions tell doctors more than the lab results or vital statistics in the patientís chart.
"A hospital experience can often be frightening for patients regardless of their condition," Dr. Fujimoto says. "One of the more rewarding parts of my job is being able to help calm my patients and see them through some very difficult illnesses."
"You have to know how to listen and what to listen for. You have to be able to dig deeper to get the information and get to know whatís happening with your patient," Dr. Neme says. "When you get to that level, you can often become very attached to a patient because you have shared so much."
Patients become attached to their hospitalists too. Ronald Boyd, 65, was admitted with a severe bacterial infection in his leg. After seven days in Dr. Nemeís care, the infection has subsided. Boyd says Northwest Hospital is lucky to have a physician like Dr. Neme on staff. From his hospital bed, Boyd recalls how Dr. Neme visited him the night before, sat in a chair by his bed and chatted with him for more than 20 minutes.
"It felt, to me as though I were sitting and talking with an old friend who just happened to be my doctor," he says.
After Boyd, Dr. Neme has four more patients to see in 3 South, the hospitalís critical care unit, another four upstairs and one more in Endoscopy. Including consults, he is seeing more than 15 patients today. Despite the busy schedule, he takes a moment to discuss Boydís discharge with senior social worker Emily Butchers. The two then meet with Boyd to review treatment, follow-up care and a short-term stay in a skilled nursing facility.
"Dr. Neme is always willing to have an impromptu conference with patients and their families," Butchers says. "He partners with his patients, and with nurses and social workers like me, to formulate a plan that fits the patientís needs."
While Dr. Neme continues his rounds, Dr. Fujimoto heads to 2 North to visit three of his patients. In the pocket of his white coat is the Pocket Medicine Guide he always carries with him. He pokes his head into a patientís room, waves and says, "Iíll be right in," before detouring to the charting room to make a few notes before his visit. The patient is Mary Wahl, 83, who has had a fever and urinary tract infection (UTI). When Dr. Fujimoto comes in, she brightens and sits up straighter in the bed.
"Can I go home today?" she asks.
"Well, Iím just not sure yet," he says, leaning over her bedside and placing a hand on her shoulder. "Iíd like to call a physical therapist to come down and assess how youíre getting around. If not today, then definitely tomorrow, though. What do you think of that?"
Dr. Fujimoto frequently treats elderly patients with UTIs. If not treated carefully, routine cases like Wahlís can become complicated. Dr. Fujimoto says he prefers to err on the side of caution. Wahl calls her time under Dr. Fujimotoís care her "best hospital experience" to date.
"He has been there every day for me," Wahl says. "I was much sicker than I thought, and he has always smiled and tried his best not to scare me."
After requesting Wahlís physical therapy consult, Dr. Fujimoto visits two other patients on the unit. One is an 87-year-old woman with acute renal failure and the other, a woman with presumed H1N1 virus and bacterial pneumonia, who is also 32-weeks-pregnant.
"She feels pretty well today, but weíre really careful with pregnant women and the flu," he says grabbing a quick pump of antibacterial gel and putting on a gown, gloves and mask before heading into the room.
Dr. Fujimoto is adding the last orders to the chart when the physical therapist arrives to see Wahl. While she walks Wahl down the hall, a social worker makes calls to arrange Wahlís home care and Dr. Fujimoto discusses a discharge plan with the nurse. At this point, all four care team members are working simultaneously for the patient. This multidisciplinary team approach is what Dr. Fujimoto says made him want to join Northwest Hospitalís inpatient team.
"You get to know everyone very well because you see and work with them all the time," he says. "This directly benefits patient care because you know everyoneís strengths and weaknesses. The staff is comfortable with one another, and is used to collaborating on any concerns they have."
"You have to be able to rely on your team," Dr. Neme says. "I consider the nursing staff an extension of myself and Iím confident my patients are receiving the best possible care when Iím not with them."
What Keeps Them Going
The doctors say working as a hospitalist has its challenges. Since they donít have a history with their patients, they must get to know them much more quickly. Their patients are also more acutely ill than patients they might see as internists in an office practice. The hours are often long and some cases can be intense and emotional. But both doctors agree that being a hospitalist also has its advantages. They are much more familiar with the hospital, its staff, technologies and resources. They can consult immediately with other expert physicians and they have a broad range of diagnostic tools and treatments available at their fingertips.
Thereís also a bit of instant gratification. Each says there is no better reward than watching a patient who came into the hospital critically ill, stand up and walk out, completely healed.
Every once in a while the hustle and bustle on the patient floors calms for a moment. Both hospitalists say the quiet is deceptive.
"There is never a dull moment," Dr. Fujimoto says. "You never have a boring day here."
Dr. Neme says his seven-day work weeks go by really fast. For now, the day is done. All the boxes on his patient list are checked off and he heads home. He has no plans tonight.
"I plan so much for my patients that sometimes I like to leave my life unplanned and see what comes up," he says.
Tomorrow morning, he will get up and do it all over again.