Notes on Shadowing a Hospitalist
16 observations on hospital culture and incentives
I recently shadowed a hospitalist during a 10-hour shift. A hospitalist is a generalist doctor responsible for patients while they are in the hospital. They go through similar training to the doctors you see for your annual check-ups.
Unlike ER doctors, who handle immediate crises hour-by-hour, hospitalists manage the day-to-day care of patients with serious but not immediately life-threatening conditions.
At any given time, a hospitalist usually manages 8–10 patients, most of whom are new to them. Their job is to quickly gather information from medical records, patient conversations, and test results in order to make diagnoses and eventually discharge patients.
Hospitalists function as medical coordinators. They are trained in high-level diagnosis but quick to refer to specialists for specific interventions. In many ways, they act like PMs of the hospital: aligning stakeholders, tracking progress, and ensuring patients are on course. They can order tests such as MRIs but typically leave interpretation and detailed recommendations to specialists (e.g. surgery).
The following are a select assortment of notes from my visit:
Everyone jokes about death.
Everyone including the doctors, nurses, and support staff all joke about death in a way that is jarring to an outsider. This is best interpreted as emotional compartmentalization as a survival mechanism, not callousness. This makes sense, as it enables them to create a barrier between themselves and death. I imagine it’s one of the most effective ways to create a positive work environment while enabling everyone to do their best work without being depressed all day seeing people who are about to die.
Verbal communication dominates for up-to-date knowledge transfer, while written notes are often an afterthought.
When I first arrived, four surgeons were holding a stand-up meeting at a nearby table. The overnight surgeon recounted the nuances of a surgery she had just performed, while the others tried to listen and skim the patient’s chart at the same time. She had to repeat herself multiple times as they asked questions she had already answered.
When doing the morning rounds, the hospitalist never took notes during the meeting. The two medical students doing their rotation were taking notes in their notebook. In the hallway after meeting with the patient, the doctor and the medical students would discuss diagnoses and recommendations for next steps. There was very little disagreement as the next steps were usually clear. In one instance, the medical student reminded the hospitalist of one of the symptoms that the hospitalist had forgotten about during the 15 minute conversation. The hospitalist usually would keep everything to memory but sometimes wrote a quick 1-5 word note on their phone for future charting.
In the afternoon, medical students wrote detailed reports on the patients they had seen, joking with doctors that it wasn’t the best use of their time. The hospitalist reviewed these write-ups as part of the students’ end-of-rotation evaluations.
I asked whether they ever revisited old cases to track patient progress. Both shook their heads: “No, that isn’t part of the curriculum—and we’re way too busy.”
Information asymmetry among staff leads to repeated explanations and lost context due to a primarily verbal communication culture.
Because documentation is written retroactively (typically at the end of the day or the next day), the most up-to-date information is acquired by asking around. This leads to manhunts, tracking down individuals around the building to acquire a specific piece of information that could have easily been written down.
Everyone hates Epic.
The quality of your medical care may be determined by carrier reception while a specialist is eating lunch.
The hospital I visited is part of a HMO system. This means hospitalists and specialists are employed by the same organization, enabling more regular communication and shared context.
There were multiple instances where the hospitalist called a specialist for a second opinion reading a chart or thinking through a recommendation. Often, we were in a wing of a building with very poor cell reception, likely due to the machinery and other cell signal limiting infrastructure. All calls were routed via standard cell carriers, not Wi-Fi (even though the Wi-Fi was consistently good throughout all points in the building). There were multiple instances of difficult to interpret segments of calls due to poor call quality.
On the call, a specialist would recommend a specific medication and the hospitalist would type it into Epic and see 8 medications populate in the search query. The hospitalist followed up to ask which one it was. It turned out to be the fourth option, masked behind the noise of a sandwich, chips, and a relatively thick accent.
Hospitalists are fine-tuned extrapolation machines.
The job of a hospitalist is to make accurate diagnoses given all available information. Information is either test results or discussions with the patients themselves.
Test results give you lots of clues and are generally accurate. However, doctors are trained to treat patients, not test results.
Patients lie frequently, and the best doctors treat this as part of the negotiation, giving the best care possible within existing constraints (available tests, insurance, etc.). Patients often lie to doctors and tell half-truths. Years of training allow them to make rapid judgments based on both conscious and subconscious cues.
In many ways, they are part negotiators and part matching engine.
Doctor competence is highly variable, as there are few incentives for improvement.
The hospitalist I was shadowing had one of the lowest average number of days patients stayed in the hospital, evidence of his ability to efficiently make diagnoses and get the patient out of the hospital. Ceteris paribus, this is a good thing as being in a hospital is bad for your health as you are sedentary and stressed.
Subjectively, he was one of the better hospitalists present that day (I also shadowed two others briefly throughout the day during slow periods). The other two hospitalists operated with much less urgency and agency.
For a patient in their mid-60s, the high-agency hospitalist I was shadowing ordered a specific test not required given symptoms, coming back positive for cancer. This likely found the cancer at least 3-4 months earlier than it would have otherwise been found.
But all hospitalists are paid under the same schedule (based on years of experience), meaning that the high-agency hospitalist is getting paid the same as their counterparts. Greater intrinsic motivation and competence are not explicitly rewarded.
Doctors know who’s good, they just won’t tell you.
One orthopedic surgeon in the organization is in his 60s and has performed many knee surgeries. One of the most common procedures is for torn meniscus. This surgeon had been trained only to remove the entire meniscus, a practice no longer recommended because it can lead to earlier arthritis. This surgeon does not perform meniscus repairs, which have been the preferred method for the past 10–20 years.
Hospitalists and other doctors are aware of these differences. They generally recommend alternative surgeons trained in meniscus repair, while sending older patients – who would likely receive a full meniscus removal anyway – to the removal surgeon.
Hospitalists will always say platitudes like “X is a highly capable surgeon”, even if they aren’t at the top of their list.
Doctors are mostly incentivized to be highly agreeable and take little risk.
Being contrarian and right is unrewarded and increases the workload of your peers. Common diagnoses are safe and will not deplete your malpractice insurance.
Everyone gets to go home to their kids sooner.
The social divide between doctors and nurses is palpable.
While the HMO hospital creates a flatter structure between all hospital staff, there is still clear tension between doctors, nurses, and support staff. During break periods around their desks, nurses would frequently be chatting around each other in relaxed positions as they update each other about their lives.
When a doctor tried to join the conversation, the dynamic changed, and it never felt quite the same. Conversation topics would often shift, creating a sense of forced friendliness.
Most hospitalists neither discuss work at home nor actively encourage their children to pursue a career in healthcare.
Many enjoy the high-stress nature but do not push their children toward the same path. Work is seen as a means to an upper-middle class life.
Everyone wears the same shoes.
Scrubs are more or less standard for nurses. There is surprisingly little coordination in exact uniform shades; you can see slight variations of blue or purple among their outfits. All doctors wear the same standard white coat.
The only attire choices people have are their shoes. Every single shoe I saw was either Hokas or Ons. If one believes in efficient markets, these must be the most comfortable shoes.
Being obese is very, very bad.
Not surprisingly, overweight and obese patients made up the majority of patients from the people I saw.
Being obese comes with many practical limitations. Larger beds with stronger motors are often required, and multiple nurses may be needed to help reposition patients.
One person was too large to fit into an MRI machine and had to be transported 20 miles to another hospital with a larger machine. This delayed her care by over a day and led to many miscommunications internally and frustration for both the patient and their partner.
The patients without close family are the most dismissive.
Patients who have many family members present, or who reference close family when asked, tend to be the most optimistic and the most willing to absorb and act on new medical information from their doctor.
Security is surprisingly lax.
There were contracted security guards at the major entrances, but they only did cursory checks. I would classify the level of security as similar to what you’d find at a concert.
If you come in with a backpack, like I did, it is only checked once before you receive a name tag. You can leave and come back with the same backpack and it won’t be checked again.
It’s easy to lose perception of time.
Most areas of the hospital are lit entirely by artificial LED light, with no exposure to natural sunlight, making it very easy to lose track of the time of day. The hospitalist I was shadowing compared the hardest part of his job to simply getting to work, similar to how going to the gym is often the hardest part of exercising.
Once you’re there, the time flies by.
Prediction hash: 48147cd4747bafd4461c68ee7469679ff2427f4b16c6d79f8d99185a484759d
Everyone, universally and without exception, that has come within arms length of epic, hates Epic.
For most of our users, we use virtualization for it, but some machines need direct, manually repackaged installs. Building these install packages led to a deep disdain for the depravity of the staff at Epic who make said install packages.
A clean uninstall and update takes upwards of 30min on a fast machine.
They were not all fast.
Hospitals in my area use hospitalists as "bouncers", basically. Even thought the primary doctor assigned to your case may be ordering additional tests, waiting for results, or whatever, if the hospitalist determines otherwise, you'll be discharged in short order.
This is the hospital administration perverting (abusing even?) the usual duties of a hospitalist, no doubt, but around here (Southern U.S.), it's a well-known fact. If the hospitalist says you're out, you're out. It seems to hinge on the hospital's knowledge of the balance between length of the stay/costs of the stay/etc. vs the ease or difficulty with which payment can be collected from the insurance company.
If the hospitalist walks into your room, it's not to inquire about medical matters, it's almost always to tell you that you're being discharged, no matter what the primary doctor may have told you.