The enumeration and conceptualization of the deadly sins have their roots in Aristotle's “Nicomachean Ethics,” but the Big Seven were popularized by Pope Gregory the Great in 590 A.D. Pride, greed, lust, envy, gluttony, wrath, and sloth: None of these are great personality characteristics. Hospitalists, though, have some special sins of their own.
Of the deadly hospitalist sins, this is one that will impact your home life, your team, your hospital, and most important, your patients. When rounds take six hours and tests don't get ordered on time, patients stay longer and the census climbs. Teammates get frustrated, and so do the patients. Everyone has gone home, it's 9 p.m., your shift is long over, and there are still 10 notes left to write. You miss your kids' soccer game and dinner. Your quality of life does not meet even the minimum parameters.
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Documentation accuracy is so important to adequately capture patient complexity, to communicate with other clinicians, to bill appropriately, and to protect against audits or lawsuits. But how can it be accurate if the patient's glucose is 86 mg/dL every day and you are “continuing home meds” on day 14? And how is the exam completely unchanged despite an ICU stay and pneumonia? Documentation accuracy is so important for the adequate capture of patient complexity, to communicate with other clinicians, to bill appropriately, and to protect against audits or lawsuits. But how can it be accurate if the patient's glucose is 86 mg/dL every day and you are “continuing home meds” on day 14? And how is the exam completely unchanged despite an ICU stay and pneumonia?
Thanks, copy and paste.
You refuse to see a new consult if the order is put in after 3 p.m. That admission should go to surgery, or neurology, maybe the MICU, not to your service. In fact, you're thinking gyn/onc might be best, until the ED doctor responds that the patient is a man. You spend two hours fighting to avoid 30 minutes of work. It's the battle that counts.
You're working with a new PA, or maybe an intern, who orders 20 mEq of KCl for a patient who is mildly hypokalemic. You change it to 10 mEq and then berate your teammate for overadministration. You don't like the choice or route of diuretic, the antibiotic administered, or the grade of the systolic murmur. (You even have some suggestions about this column.)
You have a research meeting, you are on the facilities committee, or perhaps both. You leave the NP with the service pager, then come back late. Your patient has a CT scan that you forget to check, but you spent an hour checking emails, then your Twitter account. It's the on-call person who notes your patient's pulmonary embolism at 10 p.m. and starts heparin. Like a driver texting on a cell phone, you wander the hallways distracted by everything without focusing on the most important thing, your patients.
What could be more important than the handoff? Your shift is over, and it is key that the person covering at night or picking up the service Monday knows all the pertinent details of pending tests, family psychodramas, surgical decision making, or ongoing code status discussions. Instead, your colleague starts the shift in a state of enforced ignorance. Like a relay racer who drops the baton, or a football player who loses the ball, you just fumbled.
That's right, gluttony is on both lists. When it comes to food, drink, and other excesses, gluttony leads to obesity, gout, and a variety of spiritual and corporeal ills. When it comes to the hospitalist, the unrestricted desire to use health care resources is an equivalent sin, leading to a variety of complications due to overconsumption. You just admitted a 94-year-old with confusion? Better order some tests: CBC, BMP, LFTs, lactate, ESR, CRP, SPEP, UPEP, HIV, HBV, some levels (zinc, copper, chromium, vitamins D and A), Wassermann, and another CBC just in case. And while you're at it, make sure to get an EKG, CXR, CT, U/S, PET, HIDA, and panoramic X-ray. Then get consults from neurology, psychology, orthopedics, vascular surgery, social work, nephrology, and endocrine. Then get another CBC.
We can all try to avoid these sins and should aspire to the virtues instead: compassion, teamwork, diligence, humility, patience, stewardship, and great documentation!