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Cartoon: Why Are Hospitals So Noisy?

How To Make Inpatient Medical Practice Fun Again: Try Locum Tenens Work

It’s no secret that most physicians are unhappy with the way things are going in healthcare. Surveys report high levels of job dissatisfaction, “burn out” and even suicide. In fact, some believe that up to a third of the US physician work force is planning to leave the profession in the next 3 years – an alarming statistic.

Direct primary care practices are touted as the best way to restore patient and provider satisfaction. Those brave enough to cut out the “middle man” (i.e. health insurers, both public and private) find a remarkable reduction in billing paperwork, unrecovered fees, and electronic documentation requirements. I know many physicians who have made the switch and are extremely happy to be able to spend most of their time in direct patient care, unfettered by most rules, regulations, and coding systems. They can solve problems via phone, email, text, video chat, or in-office as the need arises without having to worry about whether or not their manner of interaction will be reimbursed.

Direct primary care is probably the best way to find freedom and happiness in practicing outpatient medicine. But where does that leave physicians who are tied to hospital care due to the nature of their specialty (surgeons, intensivists, anesthesiologists, etc.)? Is there any way for them to find a brighter way forward?

I have found that working as a locum tenens hospital-based physician has dramatically improved my work satisfaction, and it may do so for you too. Here’s why:

1. You can take as much time off as you want, anytime you want. Do not underestimate the power of frequent vacations on your mental health. The frenetic pace of the hospital is much more tolerable in short doses. My attitude, stamina, and ability to stay focused is dramatically improved by working only 2-3 week stretches at a time. When I feel good, I can spread the cheerfulness, and I am happy to spend longer hours at work to give my patients more of my time.

2. You can avoid most political drama. Hospitals are incredibly stressful environments filled with hierarchical and territorial land mines. Being a short-timer allows you to avoid many conflicts. Administrators never nag you, or hold you responsible for perceived departmental deficiencies. You don’t need to attend committee meetings or become involved in personality quirk arbitrage. You can stay above the fray, focusing purely on the patients.

3. You learn all kinds of new things. Exposure to different patient populations, hospital expertise and different peer groups exposes you to a broader swath of technology and humanity. No longer will you be tied to the regional practice idiosyncrasies of a single hospital – you’ll learn how to tackle problems from many different angles. That knowledge earns you respect, and serves to cross-pollinate your own specialty, making you – and those you learn from – better doctors.

4. You are free to leave. There’s something refreshing about knowing that you can leave a place that you don’t like without any repercussions. No matter how unpleasant a locums assignment, it will end, and you can saunter off to brighter pastures.

5. You make more money. Believe it or not, locums work can be quite lucrative if you find the right assignments. I know a team of hospitalists who travel the country together, negotiating higher rates since they are a “one stop” solution. Their housing, travel, and cars are paid for by the agency, and they have take home pay (before taxes) around $350K per year. I personally think that working that many hours as a locum tenens physician kind of defeats the purpose of avoiding burn out, but some people like to do it that way.

6. You can live in the warm states in the winter, and the cold ones in the summer. Enough said.

7. You can try before you buy. Maybe you’re not sure where you want to sink down career roots. Or maybe you’re not sure you’ll like living in a certain city or part of the world? Maybe your family isn’t sure they want to move to a new location? Locum tenens assignments are the perfect way to try before you buy.

8. You can use your experience to become an excellent consultant. With long term exposure to various hospital systems, you are in a unique position to develop an encyclopedic knowledge of best practices. Sharing how other hospitals have solved their challenges can spark reform at other institutions. You can become a real force for positive change, not just on a micro level, but system and state-wide.

Working as a locum tenens physician may enhance your career satisfaction and promote professional advancement. What it will not solve, however, is the following:

1. You still have to work within the framework of bureaucracy endemic to hospitals. You’ll need to learn to use multiple different EMR systems and fill out most of the same paperwork that you do as a full-timer. This is painful at first, but once you’ve mastered the most common EMR systems (I’ve only really encountered 5 different ones in 2 years of locum tenens work) you’ll find a clinical rhythm that fits into most frameworks.

2. You will be living out of a suitcase. If the disruption of frequent travel is too much for you (or your family) to bear, then perhaps the locums lifestyle is not for you.

3. You will be annoyed by the process of getting multiple medical licenses and hospital credentialing. Agencies try to help with this burden, but mostly, you’ll need to suffer through this part yourself.

4. You will have to live with some degree of uncertainty. Part of the nature of working as a locum tenens physician is that clients (hospitals) change their minds frequently. They try to fill open positions with local staff or hire additional full-timers, using locums as their more expensive back ups. Assignments fall through frequently, so you’ll need to be ready to change course quickly.

Overall, I believe that locum tenens work can provide the practice freedom that many hospital-based physicians crave. If you’re eager to get off the unrelenting clinical treadmill, this is an easy way to do it. At a recent assignment near New Hampshire, I mused at the license plates that I passed on my way to work: “Live free or die” is their state motto. And I think it captures my sentiments exactly.

The Ten Worst Hospital Design Features: A Family Member’s Perspective

An ICU Bed False Exit Alarm

I just spent the last 8 days in the hospital, at the bedside of a loved one. Although I squirmed the whole way through a tenuous ICU course and brief stop-over in a step-down unit, it was good for me to be reminded of what it feels like to be a patient – or at least the family member of one – in the hospital. The good news is that the staff were (by and large) excellent, and no major medical errors occurred. The bad news is that the experience was fairly horrific, mostly because of preventable design and process flaws. Having worked in a number of hospitals over the years, I recognized that these flaws were commonplace. So I’ve decided to tilt at this great hospital design “windmill” on my blog – with the hope that someone somewhere will make their hospital a friendlier place because of it.

Most of these design and process flaws have one thing in common: they prevent the patient from sleeping. In some circles, sleep deprivation is an organized form of torture reserved only for the most dangerous of terrorists. In other circles, it is hospital policy. And so, without further ado, here is my top 10 list of annoying hospital design flaws:

#1: False Alarms. Every piece of hospital equipment seems to be designed to beep for a complex list of reasons, many of which are either irrelevant or unhelpful. I snapped a photo of a particularly amusing (to me anyway) alarm (see above). This was a bed alert, signaling the “patient exit” of an intubated and sedated gentleman in the ICU. Not only was the location of the alert sign curious (if you could get close enough to the alert screen to read the text, you would surely already have noticed that the patient was AWOL) but it was triggered by mattress pressure changes that occurred when the patient was repositioned every 2 hours (as per ICU pressure ulcer prevention protocol).

The I.V. drip machines are probably one of the worst noise pollution offenders, beeping aggressively when an I.V. *might* need to be changed or when the patient coughs (this triggers the backflow pressure alarm, leading it to believe that a tube is blocked). Of course, I also thoroughly enjoyed the vitals monitor that beeped every time my loved one registered atrial fibrillation on the EKG strip – a rhythm he has been in and out of for years of his life.

#2: Intercom Systems. Apparently, some hospital intercom systems are wired into every patient room and permanently set at “full volume.” This way, every resting patient can enjoy the bleating cries for housekeeping, tray pickup, incoming nurse phone calls,physician pages, and transport requests for the entire floor full of individuals undergoing the sleep deprivation protocol.

#3: The Same Questions Ad Nauseum. Over-specialization is never more apparent than in the inpatient setting. There is a different team of doctors, nurses, PAs, and techs for every organ system – and sometimes one organ can have four teams of specialists. Take the heart for example – its electrical system has the cardiac electrophysiology team, the plumbing has the cardiothoracic surgery team, the cardiologists are the “minimally invasive” plumbers, and the intensivists take care of the heart in the ICU. Not only is a patient assigned all these individual micro-managing teams, but they work in groups – where they rotate vacations and on-call coverage with one another. This virtually insures that the sleep-deprived patient will be asked the same questions relentlessly by people who are seeing him for the very first time at 20 minute intervals throughout the day.

#4: Inopportune Intrusions. There are certain bodily functions that benefit from privacy. I was beginning to suspect that the plastic urinal was attached to the staff call bell after the fifth time that someone summarily entered my loved one’s room mid-stream. Enough said.

#5: Poorly Designed Tubing. Oxygen-carrying nasal cannulas seem to be designed to maintain a slight diagonal force on the face at all times. This results in the slow slide of the prongs from the nostrils towards the eye. Since the human eye is less efficient at absorbing oxygen than the lungs, one can guess what might happen to oxygen saturation levels to the average, sleep-deprived patient, and the resulting flurry of nursing disturbance that occurs at regular intervals throughout the night (and day). My loved one particularly enjoyed the flow of air pointed directly into his left eye as he attempted to rest.

#6: The Upside Down Call Bell. In an age of wireless technology, where almost every American has a cell phone and/or a flat screen television, it is odd that the light, TV, and nurse call bell control system must be tethered to a short  cord positioned just outside of the patient’s reach. The controller is also designed so that the cord comes out of the box’s farthest point, causing it to remain upside down in the hands of anyone lucky enough to reach it from a chair or bed.

#7: Excessive Hospital Bands. In addition to multiple rotating IV access points, my loved one’s wrists and ankles were tagged with not one but four hospital band identifiers, including one neon yellow band sporting the ominous warning: “Fall risk.” If that little band is the only way that a staff member can ascertain a patient’s risk for falling down unassisted, then one is left to wonder about their powers of perception. In a moment of rare good humor, my loved one looked down at his assorted IV tubes and three plastic wrist bands and concluded, “I’m one stripe away from Admiral.”

#8: The Blank White Board. Sleep-deprivation-induced delirium can be rather disorienting. To help patients keep track of their core care team names, most hospital rooms have been outfitted with white boards. Ideally they are to be filled out each shift change so that the patient knows which activities are scheduled and the names of the staff that will be performing them. Filling out these boards is tiresome for staff members (not to mention that the dry erase markers are usually missing) and so they remain blank most of the time. This has an anxiety producing effect on patients, as the boards boldly proclaim that no nurse is taking care of them, and no activities are scheduled.  I also noted that the size of the board lettering was a fraction smaller than a person with 20/20 vision could make out from the distance of the bed.

#9: The Slightly-Too-Tight Pulse Oximeter. Because being tethered to a bed with IV tubing, telemetry cords, and a nasal cannula is not quite irritating enough, hospital staff have devised a way to keep one unhappy finger in a constant, mild vice grip. This device monitors oxygenation status and helps to trigger alarms when nasal cannulas achieve their usual peri-ocular destination every 30 minutes or so.

#10: The Ticking And Creaking IV Drip. During the few rare moments of quiet, we did not enjoy any sort of blissful silence, but rather the incessant ticking of the I.V. drip machine. My loved one remarked that he felt as if he were trapped in an endless recording loop of the first 5 seconds of the TV show “Sixty Minutes.” And so if the alarms, tethering, interruptions, PA announcements, tubing, or white boards didn’t drive you mad, the auditory reinforcement of a ticking time bomb next to your head could bring you close to tears.

And so, because of all these nuisances (not to mention the ill-fitting hospital gowns, inedible food, and floors covered with various forms of “seepage” that penetrated patient socks on hallway ambulation attempts) we had one of the most unpleasant experiences in recent memory. All this, and no dissatisfaction with the surgical team or the primary procedure performed during the hospital stay. In the end, it’s the little things that can drive you crazy – or make you well.

WHO Report Outlines Problem Of Hospital-Acquired Infections

The World Health Organization’s new patient safety envoy will take on health care acquired infections in his new role, he announced last week. Liam Donaldson, England’s former Chief Medical Officer, pointed out in his first report as envoy that patient safety incidents occur in 4% to 16% of all hospitalized patients, and that hospital-acquired infections affect hundreds of millions of patients globally.

A WHO report outlined the problem.

High-income countries had pooled health care acquired infection rates of 7.6%. The European Centre for Disease Prevention and Control estimated that 4.1 million Europeans incur 4.5 million health care acquired infections annually. In the U.S. the incidence rate was 4.5% in 2002, or 9.3 infections per 1,000 patient-days and 1.7 million affected patients.

In Europe, these infections cause Read more »

*This blog post was originally published at ACP Hospitalist*

One Nurse Opens Her Heart And Talks About Her Life In The Medical Field

Well, not my heart.

I was contacted awhile ago and asked if I wanted the chance to read and review Tilda Shalof’s new book, Opening My Heart.  (Amazon link, but NOT an affiliate link – I live in California and due to a new law, Amazon has cut all ties with us).

I had the chance to include a story in a book that Tilda edited a couple of years ago called Lives in the Balance.  So I had fond memories :)

I’ll say up front that I enjoyed the book.  I had a range of emotions while reading it – frustration, worry, happiness.  Frustration because although Tilda is a very experienced ICU nurse, she doesn’t take her own health seriously at all.  I read with disbelief as she described her incredible denial of the obvious need to treat the heart condition she was born with.

I was amused at her doctor’s and husband’s reactions when she tried to tell them that if anything went wrong with her surgery, she didn’t want to be kept alive on machines.   She explained that she used to have a dog and her husband absolutely refused to euthanize the miserable thing.  I liked this passage in particular:  “To Ivan, love means never stopping love or giving up.  This is what families say.  They can’t let go because of love.  I hope no one loves me this much, ICU nurses often say to one another.”

Amen, sister.

Tilda writes about Read more »

*This blog post was originally published at code blog - tales of a nurse*

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