The other day my senior remarked
to me, "The internists at the Southwest Community Hospital
are actually happy with their jobs. Depending on your
staff at the Inner-City Hospital, you'll either hate
it or love it. And here at the University, it's all
about politics."
As much as I enjoy ward medicine,
I couldn't help but notice how disgruntled the staff
and residents were every morning during intake rounds.
The patient should have gone to neurology, or maybe
GI, but somehow, they ended up on general medicine.
"We're not a dumping ground for patients," we grumble.
"If cardiology didn't feel Mr X needed to be admitted,
then we don't automatically have to take the patient.
Cardiology has to take responsibility for the patient
instead of getting used to having us be their safety
net." This is mostly for our benefit, because nobody
much listens.
At the University, patients can
be admitted directly to the subspecialties instead of
going to general medicine and having the specialists
as consultants. So patients with only one specific organ
problem go to the subspecialty wards. But if there's
an inkling of dementia, or CHF, or something unglamorous
that doesn't involve a high billing procedure, we get
them on general medicine.
Being better compensated for "procedure
specialties" than for "thinking specialties" is a well-recognized
problem in healthcare, but our internist attending also
suggested that, "General internists should stop giving
away procedures to our partialist colleagues."
I'd love to focus in medicine,
but the more I subspecialize, the more restricted I
am in where I work. I'd really enjoy working at the
University, teaching students and being at the forefront
of cutting edge and evidence-based medicine, but I'd
also have to contend with the dreaded bureaucracy. The
collegiality I saw in the community hospitals between
specialists was drowned in the territoriality and hierarchy
that rules at the University.
CAN
WE TALK?
It's impossible not to notice that the staff doctors
only occasionally speak to one another, leaving the
consulting process to the housestaff. I wonder when
the system developed to the point where each specialty
service became so isolated from each other. For example,
the staff for hematology wants a workup for acute renal
failure on Mrs Y. She talks to the senior who asks the
junior resident or student to consult nephrology. The
nephrology junior picks up the phone, lets the senior
know, does the consult and then reviews it with the
staff. The staff consult note usually consists of two
or three sentences of suggestions. Down the chain of
command and then back up again.
I suppose it makes sense in terms
of learning for the residents, but for the staff, it
bypasses the human component to multidisciplinary medicine.
It's nice to be the expert in one's
field, shielded by a thick team of white coats all focused
on one specific area of academic medicine. It's also
nice to know the radiologist well enough to be able
to call him up at night, and have him trust you enough
to know that you wouldn't call if you didn't absolutely
need that CT.
Here on my shift, I call up fellow
residents Kris on neurosurgery or Pete on pulmonary,
thinking how exciting it all is and realizing like an
auntie who hasn't seen you for a while that "we're getting
all grown up!" Soon we'll be out there on our own as
full-fledged docs — and we'll barely speak to each
other anymore.
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