The last patient of the day gets the least care
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He entered the hospital on Monday morning with a list of patients running through his mind. From the time he received a sign out of 22 patients from his colleague on Sunday evening, he was planning his workday.
It was a ritual of his to pray and sleep early on Sunday night to prepare him for what lie ahead. What lied ahead was a busy week of inpatient medicine also known as hospital medicine. He was a hospitalist. He loved what he did. He worked hard to understand his patients as individuals and did his best to understand the diseases that ruthlessly and mercilessly afflicted them.
With time, effort and dedication, he had become a consummate clinician. He and the nurses he worked with would often marvel at his ability to predict badness. In the hospital, badness can be very bad and ugly, but most people don’t know that. He knew it well, very well indeed. Instead of focusing on quality metrics like length of stay he would focus on his patient at hand and what ravaged them. He almost always was able to figure out who the patient was and what his disease was. He would put two and two together, diagnose and then treat the disease, ask his specialist colleagues for help when needed. He worked with social workers, case managers, physical, speech, respiratory and occupational therapists to guide the patient and his family out of the hospital. Sometimes patients would recover completely. Sometimes they would get worse and end up in intensive care or pass away. Sometimes, death was expected sometimes not. He was good at care of patients’ families. He would soothe and comfort them. Over time, he became adept at gaining the confidence of patients and their families early in their hospital course. He really cared and was good to them.
He listened to his patients and families patiently as his pager and cell phone rang incessantly often at the most inopportune of times. He paid attention to all of the information flowing his way from all sources and used it to arrive at the best plan for each patient every day. Ten years after he completed his training, he was able to become what he craved to be in his medical school years a master clinician. He read latest medical literature, attended lectures and conferences as often as he could. But he knew that he would learn the most by caring for his patients and spending time with them. His colleagues knew that every patient of his would be worked up and cared for in the best possible way. To him what mattered the most was the health of his patient and their well-being. He often prayed for them and took the time to think over their diagnosis and plans for them. These are the things that make a quality physician and that’s not what is being measured these days.
He had become immune to the politics of the hospital, the alarms, the smells, the daily grind that it had become to be a physician but never to the pain. The loss of his youngest brother had opened his eyes to the suffering of others. He usually saw 15 to 30 patients a day. He would go from room to room holding his laptop, seeing patients, typing his notes and ordering medications. His rounds lasted several hours with interruptions from phone calls, pager rings, texts, family meetings, consultations and reviewing charts. His favorite was meeting with his administrators to go over his performance, documentation and quality metrics. He spent hours a day typing notes in poorly designed and clinically irrelevant computer programs known as EHRs. To his non-physician bosses that single activity was the most important as it generated the revenue.
He had learned well from his experience and masterfully documented brief but great prose, which served the needs of his administrator masters, patients and in the case of litigation him. He would admit and discharge patients all day long. He made extra effort to understand the observation versus admission rules to serve his patients better. After all, with this experience, he had become an exemplary “provider” of inpatient care.
But despite all this, he could not serve his last patient as well as he had always served others. He saw several dozen patients a day but despite his dedication and discipline he on most days he ignored his last patient. Despite his best efforts, the last patient proved to be the hardest to care for. He simply could not care for him; he just did not have the time or energy left to look after this patient’s needs. Despite understanding all the pathophysiology and his well-honed diagnostic and therapeutic prowess, he would simply abandon this last patient almost every day. You see, he was his own last patient every day. If he had 22 patients that day, he would be the 23rd, if he had 29 patients to see he would be the 30th. He simply could not care for himself while caring deeply for the rest.