A physician asked me a question regarding what should be the role of hospitalists in carrying out discharge orders written by other physicians.
I have been following your blog since I was a resident and recommend it to a lot of people. Thank you so much for enlightening me on so many day to day hospital issues. I wanted to know your opinion about something that puzzles me. When a specialist changes a medication or requires a lab to be done as outpatient after a discharge order is written (for example you write: okay to D/C if okay with cardiology, and they change a dose or request stress test out-pt) who is required to write the new scripts and arrange that test? Is it the hospitalist’s responsibility to do it? Or is the specialist who changed the dose after you rounded required to handle it? It was easier during residency due to abundance of residents/fellows and the fact it was electronic RX access. What are your thoughts? As so far I always return back and make the adjustments needed for the patient welfare, and the fact I don’t know whether I should take stance and request that physician to do their job.
Dear physician, there is nothing puzzling here. It’s black and white. The doctor who ordered the test is the doctor responsible for acting on its implementation and responding to the consequences of the result. I have worked hard this year to try and change the culture of communication regarding critical lab values. This is first and foremost a patient safety issue. I have no business acting on objective data points requested by another physician because my action plan may be different than theirs. This is especially true when I am cross covering dozens of patients and have limited knowledge about their day to day needs.
I am happy to report that Happy’s hospital nurses have done a phenomenal job of appropriately communicating critical objective results to the appropriate ordering physician service. It turns out, a little education goes a long way for making things right. This educational initiative is more successful than I could have ever imagined. Thank you. Thank you. Thank you for a job well done. The difference does not go unnoticed on my end and my patients are getting orders from the appropriate service to manage critical patient care issues. My years of playing defacto first pager call for other physicians has ended for good. Patient issues are being addressed by the physician service who requested the data. And that’s the right way to care for patients.
Hopefully, this improvement will have staying power by being systematically codified into the work flow of doctor-nurse communication. Hopefully, the first question any nurse asks themselves before calling a physician is who needs to know, not who’s the easiest for me?
I know why communication interruptions had became so intolerable. It’s called the convenience creep of being a hospitalist. I’m sure most hospitalists would agree. The path of least resistance became the path of the hospitalist. I believe many doctors and nurses believed we were available for their convenience and could address patient needs on our time instead of theirs. That’s not how I run my practice nor do I allow it for my patients. I do not run a free skut service for other physicians.
I used to get called night and day with critical findings on studies ordered by other physician services. It rarely happens any more. When hospitalists cross cover 60-70 patients in a night, we have no business fielding calls and addressing medical needs for orders initiated by other physician services. That’s a patient safety issue. I am quite happy addressing critical needs on my patients in a timely manner. I am not willing to play first call pager for any other doctor on the case.
Convenience creep is not an acceptable hospital communication protocol. On many levels, the most important of which is patient safety, physicians who order tests are responsible for handling the associated consequences. If other services are difficult to contact, then that issue needs to be addressed as a patient safety issue in the medical staff process. The solution is not to call the hospitalist. And a big thank you goes out to all the nurses and managers who have helped make this happen system wide.
So back to your original questions: By providing that skut service to other doctors, for free, you are allowing yourself to be abused and placing your patients at risk for not receiving the care intended by the physician who did the ordering. While patient safety is a priority, it is not your job to run a med mal protection operation for other doctors by taking care of medical necessary orders being requested by another service. If you don’t take a stand, you will be abused until no end and your patients may be at risk for not having the ordering physician complete their discharge needs.
I refuse to allow other physicians to excuse themselves from their responsibility on discharge. Some nurses believe some doctors are too difficult to contact and believe hospitalists are just easier to complete the discharge process. This is convenience creep. That does not happen on my service because I refuse to allow it. This is bad medicine.
If you are having problems with your physician consultants not addressing orders they have implemented, simply write an order that states:
Contact ordering physician to clarify discharge medications and needs from their service.
If they refuse to appropriately address discharge needs related to their care, they are abandoning their patient and you should file an incident report with your medical staff services as this is a patient safety issue. Let the consequences work their way through the medical staff process. If the medical staff chooses to do nothing, then it’s time to contact the Joint Commission or other governing bodies looking out for patient safety. You might even contact your local news channel to let them know about your patient safety concerns.
Some doctors still view themselves above the process of being responsible for the orders they provide. It’s unacceptable. They should have their hospital credentials removed for being a hazard to patient safety. When this attitude is attempted on my service, it is quashed immediately. I do my job and do it well. I don’t do others’ jobs for them, unless they want to pay me the same going rate they command to do the job they feel they are above. I will gladly fill out their home medications and prescriptions for a fee equal to their average hourly compensation, payable in 3 minute increments, with a two hour minimum charge.
That, I don’t have a problem with.
*This blog post was originally published at The Happy Hospitalist*