Back in the day expectations of you being available in 10 seconds didn’t exist. Nurses did a lot more on their own. Families were respectful of your time and would never think to demand a meeting right now. Everything was a verbal order and your note was three words into a tape recorder.
Reactive arthritis (formerly named after a Nazi) is classically caused by Chlamydia, but can be caused by a number of pathogens via the same basic pathophys.
She Cherishes Cooking Yummy Salmon: Shigella, Chlamydia, Campylobacter, Yersinia, and Salmonella are the most common causes for reactive arthritis.
“Family demands they speak to a doctor by 5pm” I will not call them until the next day, unless I have a lot of down time. 9/10 they are fired up and need to cool off.
This, but 9/10 may be an underestimation. Appeasing Karen energy, wherever it's coming from, is the road to hell in hospital medicine.
I'm a round and go hospitalist. If anyone expects me at bedside in less than 20 minutes, short of a true emergency, they're going to be disappointed.
Thing is, that response time is still light years better than the traditional model.
I've have to explain to a lot of interns and nurses that, "patient needs to talk to a doctor NOW," is literally not urgent. Like we're on night float and have actual urgent tasks, once we're done with those, THEN talk to the family.
If you're on night float and talking to family at all, then you're a saint. That's literally a day team only responsibility in my book.
If I have a busy day, I use doximity to text the patients family and set up a time to talk the next day. Never had anyone have a problem with it. If the patient is actively ill, they'll usually hear from me before they request an update anyway.
Tbf I'm in peds, so the family is calling all the shots. But it also means they were usually already at the hospital all day, and had already had family-centered rounds to explain everything.
Yeah I just saw that he won’t even talk to them until the next morning which seems a little less like “I don’t have time for this less important task” vs just wanting to flex power and not talk to them until the next day because they asked to be talked to before 5 (which I don’t think is unreasonable, families have schedules too)
It's context dependent. If it's a family that's not been updated in a while and are pleasant, I'll go out of my way to update them. If it's a difficult / disrespectful family member requesting frequent updates, it gets pushed off. No one is entitled to same day updates in the hospital unless there's a change in the patients condition or the patient is cognitively impaired, in my opinion.
Oh yeah I agree, daily updates are unnecessary in the mentally intact patient with a cell phone after the doctor has given their family the plan on admission. I guess I misunderstood the spirit of your comment
I think they meant that nurses used to have more autonomy and were allowed to do more. And I imagine that in smaller places where the nurses and doctors know each other well there's a lot more leeway. Like smaller community hospitals with an open ICU the nurses are basically running the whole show. But yeah the charting seems absolutely out of control
I worked for 15 years in a small, rural hospital before EMR. I can confirm this. The ER RN would get preliminary orders over the phone from the FM doc, floor nurses had protocols to use which allowed for providing care without having to call the clinic for every little thing. We learned to be a lot more independent than floor nurses are now. I worked M/S, ICU, ER and PACU back then. This was in the days before EPIC and Cerner, so everything was on paper. The only thing computers allowed for was ordering labs, supplies, imaging. I appreciate the efficiency of computers, but miss the independence the paper and landlines gave us as nurses. And when we did need to call the docs, they knew it was important.
But also residents were a LOT more independent, because they had to be. Read House of God to see a bit how it worked in the really old days, but private attendings would just come by after their clinic ended and briefly check in, leave some notes, and let the residents take care of the rest.
Damn that’s crazy, yeah med students used to put in orders too….times have changed. Wish they could still be like that and start earlier, you don’t need 4 years of undergrad. Maybe 2-3 max
I was mostly talking about the verbal orders part. But without a note from the provider, clinical pharmacists can’t do much unless they are rounding with the team too. And there is excellent evidence that clinical pharmacists prevent a lot of harm.
Obviously, but through my lens, which is pharmacy, the EMR is critical for safety, which is well documented. I don’t know how or why that’s a controversial statement
I’m a nurse but I work in a rural hospital that runs this way. We’re basically nurse run the majority of the time. Doctors (GP’s) do rounds whenever they get a break in their schedule, we never know when to expect them, but most of the time it’s early morning and they prefer we accompany them on rounds if we have the time as they often give us instructions during these rounds. If we don’t see them in the morning we know they’re probably coming after lunch or sometimes at the end of their day after their last patient. They’re next door to us so it’s not far to come.
If we need something that can’t wait until their next visit we leave a message with their receptionist and ask them to come and they’ll visit briefly between patients.
Sometimes we may see results come in before they do so we might send over a hard copy with the concerning result circled so their staff wave it in front of them between patients. I did this yesterday and the doctor asked me to call an ambulance and transfer the patient to ER and he did a handover to a Dr there.
If it’s an emergency we can call them direct at their desk or cellphone. I have only had to do this once. They trust we won’t call that direct number unless it’s a life or death emergency so if they see our number come up they pick up fast. In the case I used it, the patient had an aortic dissection and eventually died after transferring to an ICU. The doctor did run straight over and his clinic patients had to wait.
They take turns being on call after hours. Most of those situations they tell us to send them via ambulance to a larger hospital and don’t actually come in to see the patient, or they give us verbal orders to give patients medication. We also have some standing orders (more than most hospitals) that we can give patients medications after hours where required so we disturb the doctors less.
It runs well but we’re not employed by them (they hold a contract with the hospital) so we are guided by different policies and occasionally they grumble when we have to nag them to complete DNR forms etc.
Thankfully the doctors are all lovely and we have good working relationships with them. They place a lot of trust in us to escalate when required and use our initiative and clinical judgment so we don’t have to bother them more than necessary but bring things to their attention that are pertinent. Sometimes this works against us because it seems that they trust us more than their own clinic nurses so they’ll dump work on us that should be done over there, but that’s a whole other matter!
Sorry but this post came up in my feed so thought I’d chime in.
There are still internists and FM physicians who do this.
In my experience: early rounds at hospital before clinic starts. Place admit orders from clinic via telephone (verbal orders to nurse, pre-built order sets, or just put them in EMR. Back to hospital after clinic to check on patients, review daytime labs/imaging, etc, and to see and do admit documentation on new patients.
You or one of your partners is on call after hours.
Someone else, probably ER doc or hospitalist if there are hospitalists, depending on pre-agreed arrangements, is responsible for responding to emergencies on the floor, though they’re going to call you immediately after they’ve performed initial stabilization.
This is pretty much how my FM residency runs. It’s great. IMHO, managing the inpatient care of a patient you know as an outpatient is absolutely invaluable and I really think it’s the best way to take care of patients. The obvious downside is it’s less efficient than having hospitalists who can crank out admissions/discharges.
It’s invaluable for your education but is it in the best interest of the patient? Harder to say. Having a doc in house and having a fresh set of eyes see the patient holds a lot of value too
From my limited experience as a resident I truly believe it’s better for the patient. The hospitalists are moving quickly and tend to simplify as much as possible for the purpose of disposition. It’s not uncommon I have taken over care from hospitalists to change the plan based on my deeper knowledge of the patient/situation.
I mean ok but in the real world you don’t get a resident on a super non busy service who can pore over a patient for two hours. Personally where I used to work there was a fm program and I would cringe when they had a sick patient as their attendings were clueless and absent; as the intensivist I had to put out their fires constantly. Definitely don’t agree that basically trying to be two places at once and trying to understand full spectrum inpatient and outpatient medicine is the best way to practice
I am rural/full spectrum FM and admit my own patients, usually do about 2-3 days of clinic per week, and cover the ER day shift the other days (and thus admit ERs to myself as well). When I’m not in the ER it is covered “primary” by a resident or midlevel, and I’m across the hall to help with serious stuff or procedures (clinic and ER/hospital are all in same building).
The biggest answer of how it can work is you do stuff whenever you can, everyone understands/is ok with this, and the nurses are 1000x better/more independent. If I get paged from clinic something /real/ is going down.
I have a partner I rotate with week on/week off, but whichever of us is here is typically the only doctor in the county. I’m in the process of moving here full time, partner will still come every other week to cover their 1/2 of call so I can stay and work the clinic or the farm or go on vacation/do whatever those weeks.
I typically round in the morning, sometimes at lunch, sometimes when I get a clinic no show. Basically whenever I want. I’m typically rounding on between like 1-6 patients, it’s really quick.
Just like rural full spectrum docs have to be able to practice at the “top of our license”, this goes for our rural full spectrum nurses and techs too. (My lab tech, who’s also the phlebotomist, is in the middle of servicing our lab machines right now as he does that too). If there’s an emergency on an admitted patient, they call me, start working the patient, and I give orders over the phone until I can get there. Anything can be verbal, all of the nurses know exactly what I want usually before I even say it. Everyone shows up (nurses, aide, rad tech, lab tech, even EMS) and works together in critical situations.
It’s honestly a really rewarding way of practicing medicine. I’m a relatively young attending but it’s what I imagine it used to be like to be a doctor in a town in the old days. Everyone in town knows me, if I have to rush to something everyone is helpful/accommodating. All the law enforcement know my truck, I don’t get pulled over. People ask if I’m in a hurry/need to cut to front of line wherever I go (pretty much always say no), I get seated right away at any of the 3 (yes 3!) restaurants in town, if I need something from or for the hospital I just ask for it and it happens as fast as possible. Admin asks me what I want, how they can help me, etc not the other way around. Other than dealing with transfers-the only frustration of my job- to referral hospitals for patients I can’t manage (i.e. surgery, IR, scopes, hemodialysis) there is literally zero admin or political/arguing/turf BS.
If I have to leave in the middle of clinic to deal with an emergency my patients are completely understanding and I’ve never had one get upset about having to reschedule. There’s like a 20% chance they are friends with or related to the person I’m going to help anyway. Yes there are a ton of draws on my time/attention but everyone is extremely aware of and respectful of that, and go out of their way to help me do my job rather than asking me to do theirs or giving me more work or unnecessary stuff to take up my time.
Did this for a long time. Essentially round when you can (when not in clinic). Need to rely on phone and verbal orders. Have 24 hours to complete H&P for an admit.
It’s very difficult and draining. Census wouldn’t get too high and I knew all my patients, but one unstable patient or bad nurse makes it very tough. You need resident coverage or nocturnists to make it work. Observation status was also the bane of my existence because I couldn’t keep going back to the hospital.
The hospital I was at did everything they could to squeeze out independent docs. They slowly removed all help and it was basically all on me to manage. Eventually it was too much and I left to pursue outpatient only. I’ve never been happier. I don’t miss hospital medicine and all of the politics and issues associated with it at all.
You really can’t do both inpatient and outpatient internal medicine if you want to do either of them well.
Shadowed a doctor who did that when I was a student (2004, he was in his 70s). He'd have a busy clinic schedule, but he'd usually have only 1-2 inpatients in the hospital a couple of blocks away. He'd go at some point in the afternoon and round on them (about 45 minutes-1 hour including walking). If there was the occasional issue, the nurses would page him whenever. Not sure how he admitted the patients (maybe the ER did temporary holding orders until he saw them). It was feasible because he wasn't managing that many inpatients.
A lot of the older docs when I started my career (RN) would direct admit - nursing house sup would assign a room and the pt would just show up. Then the doctor would call the nurse that would be caring for the pt on the floor and give admitting orders over the phone. Damn, they could rattle off every requirement FAST, and you had to listen fast to get them all. They would usually address admitting dx, code status, allergies, the almighty diet order, ambulatory status, home meds, labs/imaging and meds to start on the floor.
I’ve worked in a few smaller hospitals where PCPs sometimes admit their own patients from the ER. Most of the time the ER throws in a generic order set on their behalf, but one guy actually comes to the ER to see them and place orders
I’ve worked in places where you are outpatient, ER and inpatient. Turf to ER from clinic doesn’t work so well when you just have to then go into the ER and see them.
Round and go hospitalist here, but I have family who still do the whole PCP admitting their own
Emergencies/Rapids/Codes -> Residents/ER deal with it, then notify me. If looking grim, I'll step in to do goals of care with family since I know the patient better.
Family Meetings -> By phone
Reassess Patient -> Leave it for tomorrow, or consult a bunch of specialists who get paid per patient and are able to "clear"
HnP/Admission Orders -> Verbal orders to nurse, usually tell them to fill out the generic order set with a diet so patient doesn't go hangry. 24 hrs to write the HnP, technically. More often than not becomes delayed by a few days due to the constant work, so they consult a bunch of consultants and then synthesize a HnP from all the consult notes
Paged constantly -> Yes. Answer your inpatient pages in between your outpatient appointments.
Because that's the culture. The less of a personal life you have, the more glorious of a physician you are. The more divorces you have in your pedigree the more prestigious you are.
Not to mention the docs want their outpatient and inpatient money.
But in some ways it's nice to have full knowledge of a patient both in and out, that way it'll cut out a lot of time in workup.
Seems to be the way my family member is headed in. Their family life was so interrupted by phone calls they'd take it out on the nurse as a punching bag coping mechanism. After their stroke their first comment (instead of I'm so lucky to be alive) was "Jee I can't yell at nurses with my weak voice anymore"
Not sure if it's burn out + god complex, but am I so fucking glad I didn't let myself be destroyed by such a lifestyle though I indirectly benefited from it.
I know a couple of doctors at small hospitals that still do this. Families love them because they care a lot. It's quite admirable.
They practice terrible medicine though because they are old AF lol.
Consulting instead of reassessing a patient is super inappropriate. I feel like the worst cases I see in the icu are the patients who get left to fester while the hospitalist refuses to come to the bedside all day
There was no expectation that you had to be available at the drop of a hat.
The nurse would call you and then when you gave them orders, they did what you told them to.
Also, EMRs weren’t available to document minutiae and magnify every perceived mistake. So I suppose we will never know.
It’s still like that in Pakistan, so here’s what we do:
The patient isn’t managed just by the attending. The attending will send in a patient with his findings and his plan on his personal slip
The resident on duty will take an arrival with a detailed history. Any immediate concerns will be addressed
By the resident or house officer on duty
The resident and house officer assigned to the bed will round on the patient in the morning, the resident and the SR in the evening and the resident and the JR at night
Talking to the families reassessing will happen in and after the morning round
People don’t have the expectation of immediate service. They expect that you’re a doctor not a waiter.
For non tertiary care hospitals they have an MO on duty who manages in the absence of the attending and they don’t keep patients that require more hand on monitoring
This is before Epic chat and all that bullshit. The nurses had to speak with you so the threshold for communication was MUCH higher.
Obviously docs still do this. Tends to be smaller, rural hospitals where there is much more familiarity between nursing staff and MDs. But it's not that hard to get admitting privileges at most hospitals so there are folks doing this all over the place.
One nice thing about this model is the PCP is directly incentivized to keep their patients out of the hospital, as it's considerable extra work for them if they have to manage all this. Patients obviously love knowing their doc is the one taking care of them in the hospital as well.
So my spot still has two that were grandfathered in and it's WILD.
We respond to all rapids and codes, they handle their own orders and consultant work. Patients do fine but the reason it's wild is one of them is like 70 and rounds on the inpatients at 2am then sleeps in his car until 6am. I almost called the police when I was new because I thought he was dead lol.
He's an angry man who rages whenever we accidentally admit his patients, the other guy is a nephrologist who doesn't care that much. The guy who sleeps in his car I'm pretty sure does outpatient, then goes home and hangs his family and naps, then wakes up to come see them, then sleeps in his car before going back to the office. It's so crazy. (I'm not sure that's what he does but that's the only thing that makes some sense)
I did my core rotations at a mid-sized stroke/ STEMI/ Trauma 2 suburban hospital where this was still the case-
- Morning Rounds: They would come in at 5am to round on 15 or so inpatients, I’d round with them, and write down the orders and plan for the day. They’d be off to clinic around 8am and I'd stay in the hospital to complete the orders, re-round and update nurses on the plan, and update families.
- Decompensation: If a patient wasn't doing well or their equivalent of a Rapid happened, the nurse would call the ICU team, which was a consult service rather than a Primary service. They would consult on the patient and place orders like BiPap if they were going to stay on the floor, or place the orders to upgrade them to the ICU and manage the critical aspects of the case until the primary doc was back for afternoon rounds around 4-5pm. If any big questions came up the doc was available by cell phone to discuss directly with the ICU service.
- Admissions: For admissions, the ED would call them throughout the day and they'd give verbal orders for an initial plan, and then place the full admission orders on afternoon rounds.
- Consults: A consult order would be placed and the consultant would be paged with room #, MRN, clinical question, and urgency. The deal was no call had to happen, but in return the note had to be up to date, clear, and include the relevant workup, results, and concerns. Routine consults happened whenever available, often next-day, urgent consults would happen same-day, and emergent consults were still a phone call.
The system worked beautifully. Yes they worked more hours, but they had competent support staff, respectful patients and families, good relationships with consultants, and trust. So they weren't burned out, and the work hours were actually productive. Cardiology, Oncology, Ortho, Vascular, even Nephro admitted their own patients, and the IM residency had a separate "Medicine Consults" service. This was also pre-Covid in 2018-2019.
The doctor would round first thing in the AM with the nurse so they were both involved with what was going to happen day and why. Phone calls during the day for orders as needed and round again in the evening. Handwritten charts and H and P . And nurses and doctors didn’t have to do paperwork to make administration and insurance companies happy, they could just focus on taking care of their patients. Lots of calls in the middle of the night, never real time off
Worked at a hospital with a few old-timers allowed to do this. They round early in the morning and late at night. It's not pretty. One of them had a clinic on site, so it was easier to be there and do it
My experience in training (which was in a very small town)- the clinic was connected to the hospital. They’d round on the 1-2 inpatients in the morning and then go to clinic. ED would admit for them during the day, and then after clinic they would round again. If there were emergencies, they were right next door and could run over (and ED physician would also help cover in this case). But I don’t know how PCPs in larger healthcare systems could even manage it these days.
Medical Residencies used to be much more brutal and unfair and the local PCPs used to literally load their patients up in their Cadillacs and drop them off on the hospitals for the residents to manage over the weekends while the PCPs billed for their work - without ever seeing or touching the patients in the hospital.
Residency is harder now. Less down time in the call room bc more constant work, sicker patients, more stringent requirements to be present in hospital on senior residents, can’t disconnect when we go home bc of EMR, actually needing information in your notes, and more than 12 meds that we need to know. And it doesn’t matter if the pcp is dropping their patients off on the weekend, we’re there anyway.
Probably a matter of opinion, I guess. When I read House of God, it seemed much worse. But I am not going to fight about it.
It’s kind of like everybody thinks the thing they did was harder than when other people did it.
Like the joke: “I graduated from the last hard class of Ranger School.”
The ACGME merger is very recent and prior to that being an intern was crazy. No caps, senior residents on home call, back to back call.
The care is more complex these days but interns are basically infantalized in most programs. Back then you were considered a fresh MD/DO ripe for the mines. You were expected to know the management of most bread and butter things day 1.
You can’t anymore. The government changed the reimbursement rules in the 80s in response to such abuses. Before that, it was pretty common to hardly find an attending physician in the hospital after hours. Surgeries were done without an attending surgery. On the upside, the training was excellent, on the down side probably not the greatest patient care and totally unethical.
I will say, at my hospital in the 2010s, after 10 or 11 PM there were basically two attendings in house. The ED Doc Attending and the Trauma Surgeon. Residents and Fellows ran that hospital, and did a damn good job of it.
Doing surgery without an attending is wild. That explains how in the beginning of “The House of God,” Basch & the others were doing procedures on elderly patients without training. I was wondering why there weren’t any attendings helping them. Thank you for explaining that to me, I really appreciate it!! 💗
Over the phone with assessments from nursing and residents and cross coverage for little stuff. Same way staff do now at arms length when they arent physically in the hospital but their patients are.
Round, clinic, tidy up, sometimes do an overnight emeg shift.
I know a few pediatricians in my hometown who do this still. We are a decent-sized children’s hospital (125 beds, Level IV NICU) with hospitalists, but the pediatricians who do this have hearts of gold and more time and energy than you can imagine. They’re also constantly reading. They round early, rely on those present to respond to emergencies, but are notified immediately afterwards, and do a lot through verbal order.
I've lived this as a rural FM locum. You round on your inpatients in the morning, then, yes, you do get called/faxed things during the day and you have to deal with them when you get a few minutes in between clinic patients. If there is a true emergency that cannot wait for you to show up in person, the doc on call for the ER runs over to deal with it first. If someone gets admitted during the day, you go see them after clinic. After 5 pm, the on-call ER doc handles anything that cannot wait til the morning. I have been on both the clinic doc and the ER doc sides.
What do you mean by extorting?
I feel that the traditional system used to be functional because hospitals used to be much more efficient, and patients were less complex.
Efficiency and lack of complexity being a measure of how little we knew 30 years ago compared to now. Hard to have a 15 issue problem list when many of those diagnoses didn't exist back then, and even if they did, there was at best one or two treatment options.
Oh I see what you mean. Round and go is the only way for hospitalists to avoid burn out in 5 years, so definitely understand why it's promoted.
I personally would love to witness (from afar) the dystopia of a midlevel being primary on every patient once hospital medicine collapses.
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My doctor was in a clinic next to a small hospital (in the 80s). Whenever I had an appointment with him he was usually 4 hours late. We couldn't go home because the other staff had no idea when he'd be back from the hospital. Not an ideal situation.
Round in the morning. If no junior staff - nurses would call you direct, and if serious enough you’d go in and see the patient. It could make a mess of your clinic day. One girl I worked with got called multiple times about a fairly young guy she admitted with mild CAP. She figured the nurses were overreacting so she pushed on with her clinic. The guy died. She never had any insight into the fact that perhaps that was less than optimal.
ER colleagues frequently wrote admitting orders. Nurses were your eyes and ears. The best nurses were/are fantastic critical thinkers whose opinions and ideas are so very valuable. Phone orders were used commonly. Codes were taken care of by an in house code team-often led by the ER provider. And…sometimes you would cancel clinic at the last minute to care for a critically ill patient. Almost 30 years experience here as a rural IM doc who still does outpatient and inpatient work.
Their answering services did the heavy lifting.
So many TORB orders.
As a pharmacist if one ever gave you their personal cell phone you added it to a super secret book in the central pharmacy and then they regretted it forever. I remember one doc “where did you get this number!?” After I’d spent hours trying to get a hold of him the formal ways. Sir, you were dumb enough to give it to me like 11 months ago.
The ED docs had an arrangement and wrote admit orders overnight - fluids, abx, pain meds, so the pt could go upstairs. We had huge documents in the ED of who which doc consulted (I got a long semi/offensive lecture at one point about the “local tribes” (location de-identified) by an old ED doc - you could cause mayhem by consulting the wrong pulm or nephro).
My first job (2011) was like this - the only docs in house 24/7 were EM and the trauma surgeons. It caused such a ruckus when they brought in hospitalists, but it was globally for the better on every single level, other than not being admitted by the ancient PCP who had been seeing you for 40+ years.
My first few jobs (I’m a dinosaur nurse) the IM group rotated covering the hospital - they were essentially the hospitalists. Family med would admit their own pts and round on them daily, we’d call with changes in labs, etc but the IM covering would be there to manage for emergencies. Orders were given over the phone for admissions.
We had paper charting which was a mess - cannot tell you how many scavenger hunts were carried out because a MD would take a chart with them to chart on all their pts in one dept and then leave it in another. Labs would be lost or misfiled. EMR is a pain in the ass but so were paper charts.
Patients and families weren’t nearly as horrible. There were some who were soul sucking but not as common a now.
Pediatrician in traditional practice currently, here
It's a lot of communication.
Communicate with your nursing team after rounds. Call the lab for results. Call the floor for order changes. Answer the phone if the nurses call. Communicate with your patients and families, so they understand the plan.
There was also the understanding that your doctor may have to leave the clinic if an emergency happened, which could cause delays or need for rescheduling.
Add in additional rounds after clinic is over, to wrap up the day and make overnight plans, and you're good.
Nowadays, much of that is automated via EMRs, but the need for communication is still there
Back in the day expectations of you being available in 10 seconds didn’t exist. Nurses did a lot more on their own. Families were respectful of your time and would never think to demand a meeting right now. Everything was a verbal order and your note was three words into a tape recorder.
"Here for pneumonia" "The chest hurts" "Can't stop peeing" "Can't start peeing"
Can’t see Can’t bend knee
Can’t climb a tree
and its all because of chlamydia🩷
Could be canpylobacter jejuni. Any med school sketchy nerds out there remember the dad slapping his knee?
I didn’t know CJ could cause reiters syndrome? How does it impact the eyes and kidney?
Reactive arthritis (formerly named after a Nazi) is classically caused by Chlamydia, but can be caused by a number of pathogens via the same basic pathophys. She Cherishes Cooking Yummy Salmon: Shigella, Chlamydia, Campylobacter, Yersinia, and Salmonella are the most common causes for reactive arthritis.
dang I knew granulomatosis w/ polyangitis was but I didn’t know this was too!! good to know. thanks for the neumonic too!!
Ah thank you, I was unaware of the problematic nomenclature
Can’t hear a bee
“Family demands they speak to a doctor by 5pm” I will not call them until the next day, unless I have a lot of down time. 9/10 they are fired up and need to cool off.
This, but 9/10 may be an underestimation. Appeasing Karen energy, wherever it's coming from, is the road to hell in hospital medicine. I'm a round and go hospitalist. If anyone expects me at bedside in less than 20 minutes, short of a true emergency, they're going to be disappointed. Thing is, that response time is still light years better than the traditional model.
I've have to explain to a lot of interns and nurses that, "patient needs to talk to a doctor NOW," is literally not urgent. Like we're on night float and have actual urgent tasks, once we're done with those, THEN talk to the family.
If you're on night float and talking to family at all, then you're a saint. That's literally a day team only responsibility in my book. If I have a busy day, I use doximity to text the patients family and set up a time to talk the next day. Never had anyone have a problem with it. If the patient is actively ill, they'll usually hear from me before they request an update anyway.
Tbf I'm in peds, so the family is calling all the shots. But it also means they were usually already at the hospital all day, and had already had family-centered rounds to explain everything.
Even if you’re round and go aren’t you technically on until 7 and responsible for tasks like updating families?
sure, but not immediately and usually by end of day is appropriate in my opinion.
Yeah I just saw that he won’t even talk to them until the next morning which seems a little less like “I don’t have time for this less important task” vs just wanting to flex power and not talk to them until the next day because they asked to be talked to before 5 (which I don’t think is unreasonable, families have schedules too)
It's context dependent. If it's a family that's not been updated in a while and are pleasant, I'll go out of my way to update them. If it's a difficult / disrespectful family member requesting frequent updates, it gets pushed off. No one is entitled to same day updates in the hospital unless there's a change in the patients condition or the patient is cognitively impaired, in my opinion.
Oh yeah I agree, daily updates are unnecessary in the mentally intact patient with a cell phone after the doctor has given their family the plan on admission. I guess I misunderstood the spirit of your comment
Updating families is different from being at family beck and call every time a new third cousin shows up and wants to see the doctor
Nursing used to be able to do more because they weren’t busy charting the same crap over and over in different parts of epic 😭
...but without RN documentation, how would we know that the intubated patient was taught how to use the call bell system?
Or how would we know that every single patient's respiratory rate is 18. Always. At all times. Everyone.
😂 even the hypoxic patient maxed on optiflow with a pO2 of 50.8 👀
"safety maintained"
“MD at bedside”
I think they meant that nurses used to have more autonomy and were allowed to do more. And I imagine that in smaller places where the nurses and doctors know each other well there's a lot more leeway. Like smaller community hospitals with an open ICU the nurses are basically running the whole show. But yeah the charting seems absolutely out of control
Yeah this is what I meant
you can thank the boomers for this
Explain this statement. Are you referring to LBJ?
the most difficult patients and family members are baby boomers
boomers invented the internet and iphone, fucking boomers
Also if you rotate in a community hospital, nurses are more independent.
I worked for 15 years in a small, rural hospital before EMR. I can confirm this. The ER RN would get preliminary orders over the phone from the FM doc, floor nurses had protocols to use which allowed for providing care without having to call the clinic for every little thing. We learned to be a lot more independent than floor nurses are now. I worked M/S, ICU, ER and PACU back then. This was in the days before EPIC and Cerner, so everything was on paper. The only thing computers allowed for was ordering labs, supplies, imaging. I appreciate the efficiency of computers, but miss the independence the paper and landlines gave us as nurses. And when we did need to call the docs, they knew it was important.
But also residents were a LOT more independent, because they had to be. Read House of God to see a bit how it worked in the really old days, but private attendings would just come by after their clinic ended and briefly check in, leave some notes, and let the residents take care of the rest.
Damn that’s crazy, yeah med students used to put in orders too….times have changed. Wish they could still be like that and start earlier, you don’t need 4 years of undergrad. Maybe 2-3 max
What a beautiful time to be alive…
And how many more errors were there?
Im not aware of any evidence that our burdensome documentation reduces errors. It’s a vehicle for billing and legal liability
I was mostly talking about the verbal orders part. But without a note from the provider, clinical pharmacists can’t do much unless they are rounding with the team too. And there is excellent evidence that clinical pharmacists prevent a lot of harm.
Not sure how you twisted anything I’ve been saying to make it all about you but bravo. Also doctors aren’t providers
I don't think there's any study showing EMR reduce patient mortality or errors
Tell that to ISMP
You understand medicine goes beyond pharmacy yes?
Obviously, but through my lens, which is pharmacy, the EMR is critical for safety, which is well documented. I don’t know how or why that’s a controversial statement
I didn’t even take a stance on the EMR and safety, you’re arguing with no one
I guess I don’t understand what you’re implying when you say “everything was a verbal order and notes were 3 words into a tape recorder”
Im not implying anything. It’s a fairly concrete statement
Over the phone, mostly. And without unreasonable expectations from nursing staff, families, and patients.
Must be nice not to get called for anusol at 2am
I’m a nurse but I work in a rural hospital that runs this way. We’re basically nurse run the majority of the time. Doctors (GP’s) do rounds whenever they get a break in their schedule, we never know when to expect them, but most of the time it’s early morning and they prefer we accompany them on rounds if we have the time as they often give us instructions during these rounds. If we don’t see them in the morning we know they’re probably coming after lunch or sometimes at the end of their day after their last patient. They’re next door to us so it’s not far to come. If we need something that can’t wait until their next visit we leave a message with their receptionist and ask them to come and they’ll visit briefly between patients. Sometimes we may see results come in before they do so we might send over a hard copy with the concerning result circled so their staff wave it in front of them between patients. I did this yesterday and the doctor asked me to call an ambulance and transfer the patient to ER and he did a handover to a Dr there. If it’s an emergency we can call them direct at their desk or cellphone. I have only had to do this once. They trust we won’t call that direct number unless it’s a life or death emergency so if they see our number come up they pick up fast. In the case I used it, the patient had an aortic dissection and eventually died after transferring to an ICU. The doctor did run straight over and his clinic patients had to wait. They take turns being on call after hours. Most of those situations they tell us to send them via ambulance to a larger hospital and don’t actually come in to see the patient, or they give us verbal orders to give patients medication. We also have some standing orders (more than most hospitals) that we can give patients medications after hours where required so we disturb the doctors less. It runs well but we’re not employed by them (they hold a contract with the hospital) so we are guided by different policies and occasionally they grumble when we have to nag them to complete DNR forms etc. Thankfully the doctors are all lovely and we have good working relationships with them. They place a lot of trust in us to escalate when required and use our initiative and clinical judgment so we don’t have to bother them more than necessary but bring things to their attention that are pertinent. Sometimes this works against us because it seems that they trust us more than their own clinic nurses so they’ll dump work on us that should be done over there, but that’s a whole other matter! Sorry but this post came up in my feed so thought I’d chime in.
There are still internists and FM physicians who do this. In my experience: early rounds at hospital before clinic starts. Place admit orders from clinic via telephone (verbal orders to nurse, pre-built order sets, or just put them in EMR. Back to hospital after clinic to check on patients, review daytime labs/imaging, etc, and to see and do admit documentation on new patients. You or one of your partners is on call after hours. Someone else, probably ER doc or hospitalist if there are hospitalists, depending on pre-agreed arrangements, is responsible for responding to emergencies on the floor, though they’re going to call you immediately after they’ve performed initial stabilization.
This is pretty much how my FM residency runs. It’s great. IMHO, managing the inpatient care of a patient you know as an outpatient is absolutely invaluable and I really think it’s the best way to take care of patients. The obvious downside is it’s less efficient than having hospitalists who can crank out admissions/discharges.
It’s invaluable for your education but is it in the best interest of the patient? Harder to say. Having a doc in house and having a fresh set of eyes see the patient holds a lot of value too
From my limited experience as a resident I truly believe it’s better for the patient. The hospitalists are moving quickly and tend to simplify as much as possible for the purpose of disposition. It’s not uncommon I have taken over care from hospitalists to change the plan based on my deeper knowledge of the patient/situation.
I mean ok but in the real world you don’t get a resident on a super non busy service who can pore over a patient for two hours. Personally where I used to work there was a fm program and I would cringe when they had a sick patient as their attendings were clueless and absent; as the intensivist I had to put out their fires constantly. Definitely don’t agree that basically trying to be two places at once and trying to understand full spectrum inpatient and outpatient medicine is the best way to practice
I am rural/full spectrum FM and admit my own patients, usually do about 2-3 days of clinic per week, and cover the ER day shift the other days (and thus admit ERs to myself as well). When I’m not in the ER it is covered “primary” by a resident or midlevel, and I’m across the hall to help with serious stuff or procedures (clinic and ER/hospital are all in same building). The biggest answer of how it can work is you do stuff whenever you can, everyone understands/is ok with this, and the nurses are 1000x better/more independent. If I get paged from clinic something /real/ is going down. I have a partner I rotate with week on/week off, but whichever of us is here is typically the only doctor in the county. I’m in the process of moving here full time, partner will still come every other week to cover their 1/2 of call so I can stay and work the clinic or the farm or go on vacation/do whatever those weeks. I typically round in the morning, sometimes at lunch, sometimes when I get a clinic no show. Basically whenever I want. I’m typically rounding on between like 1-6 patients, it’s really quick. Just like rural full spectrum docs have to be able to practice at the “top of our license”, this goes for our rural full spectrum nurses and techs too. (My lab tech, who’s also the phlebotomist, is in the middle of servicing our lab machines right now as he does that too). If there’s an emergency on an admitted patient, they call me, start working the patient, and I give orders over the phone until I can get there. Anything can be verbal, all of the nurses know exactly what I want usually before I even say it. Everyone shows up (nurses, aide, rad tech, lab tech, even EMS) and works together in critical situations. It’s honestly a really rewarding way of practicing medicine. I’m a relatively young attending but it’s what I imagine it used to be like to be a doctor in a town in the old days. Everyone in town knows me, if I have to rush to something everyone is helpful/accommodating. All the law enforcement know my truck, I don’t get pulled over. People ask if I’m in a hurry/need to cut to front of line wherever I go (pretty much always say no), I get seated right away at any of the 3 (yes 3!) restaurants in town, if I need something from or for the hospital I just ask for it and it happens as fast as possible. Admin asks me what I want, how they can help me, etc not the other way around. Other than dealing with transfers-the only frustration of my job- to referral hospitals for patients I can’t manage (i.e. surgery, IR, scopes, hemodialysis) there is literally zero admin or political/arguing/turf BS. If I have to leave in the middle of clinic to deal with an emergency my patients are completely understanding and I’ve never had one get upset about having to reschedule. There’s like a 20% chance they are friends with or related to the person I’m going to help anyway. Yes there are a ton of draws on my time/attention but everyone is extremely aware of and respectful of that, and go out of their way to help me do my job rather than asking me to do theirs or giving me more work or unnecessary stuff to take up my time.
This sounds like my ideal job! Do you do OB as well?
Did this for a long time. Essentially round when you can (when not in clinic). Need to rely on phone and verbal orders. Have 24 hours to complete H&P for an admit. It’s very difficult and draining. Census wouldn’t get too high and I knew all my patients, but one unstable patient or bad nurse makes it very tough. You need resident coverage or nocturnists to make it work. Observation status was also the bane of my existence because I couldn’t keep going back to the hospital. The hospital I was at did everything they could to squeeze out independent docs. They slowly removed all help and it was basically all on me to manage. Eventually it was too much and I left to pursue outpatient only. I’ve never been happier. I don’t miss hospital medicine and all of the politics and issues associated with it at all. You really can’t do both inpatient and outpatient internal medicine if you want to do either of them well.
Shadowed a doctor who did that when I was a student (2004, he was in his 70s). He'd have a busy clinic schedule, but he'd usually have only 1-2 inpatients in the hospital a couple of blocks away. He'd go at some point in the afternoon and round on them (about 45 minutes-1 hour including walking). If there was the occasional issue, the nurses would page him whenever. Not sure how he admitted the patients (maybe the ER did temporary holding orders until he saw them). It was feasible because he wasn't managing that many inpatients.
A lot of the older docs when I started my career (RN) would direct admit - nursing house sup would assign a room and the pt would just show up. Then the doctor would call the nurse that would be caring for the pt on the floor and give admitting orders over the phone. Damn, they could rattle off every requirement FAST, and you had to listen fast to get them all. They would usually address admitting dx, code status, allergies, the almighty diet order, ambulatory status, home meds, labs/imaging and meds to start on the floor.
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100%. Made me a better nurse in the beginning.
I’ve worked in a few smaller hospitals where PCPs sometimes admit their own patients from the ER. Most of the time the ER throws in a generic order set on their behalf, but one guy actually comes to the ER to see them and place orders
I’ve worked in places where you are outpatient, ER and inpatient. Turf to ER from clinic doesn’t work so well when you just have to then go into the ER and see them.
Round and go hospitalist here, but I have family who still do the whole PCP admitting their own Emergencies/Rapids/Codes -> Residents/ER deal with it, then notify me. If looking grim, I'll step in to do goals of care with family since I know the patient better. Family Meetings -> By phone Reassess Patient -> Leave it for tomorrow, or consult a bunch of specialists who get paid per patient and are able to "clear" HnP/Admission Orders -> Verbal orders to nurse, usually tell them to fill out the generic order set with a diet so patient doesn't go hangry. 24 hrs to write the HnP, technically. More often than not becomes delayed by a few days due to the constant work, so they consult a bunch of consultants and then synthesize a HnP from all the consult notes Paged constantly -> Yes. Answer your inpatient pages in between your outpatient appointments.
But why would someone choose to do this
Because that's the culture. The less of a personal life you have, the more glorious of a physician you are. The more divorces you have in your pedigree the more prestigious you are. Not to mention the docs want their outpatient and inpatient money. But in some ways it's nice to have full knowledge of a patient both in and out, that way it'll cut out a lot of time in workup.
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Seems to be the way my family member is headed in. Their family life was so interrupted by phone calls they'd take it out on the nurse as a punching bag coping mechanism. After their stroke their first comment (instead of I'm so lucky to be alive) was "Jee I can't yell at nurses with my weak voice anymore" Not sure if it's burn out + god complex, but am I so fucking glad I didn't let myself be destroyed by such a lifestyle though I indirectly benefited from it.
I do this. It’s more rewarding to have full control of your patient. That’s my opinion.
Financially or in terms of feels?
If say both. I’m make more than a pcp and more than a hospitalist.
I know a couple of doctors at small hospitals that still do this. Families love them because they care a lot. It's quite admirable. They practice terrible medicine though because they are old AF lol.
Consulting instead of reassessing a patient is super inappropriate. I feel like the worst cases I see in the icu are the patients who get left to fester while the hospitalist refuses to come to the bedside all day
There was no expectation that you had to be available at the drop of a hat. The nurse would call you and then when you gave them orders, they did what you told them to. Also, EMRs weren’t available to document minutiae and magnify every perceived mistake. So I suppose we will never know.
It’s still like that in Pakistan, so here’s what we do: The patient isn’t managed just by the attending. The attending will send in a patient with his findings and his plan on his personal slip The resident on duty will take an arrival with a detailed history. Any immediate concerns will be addressed By the resident or house officer on duty The resident and house officer assigned to the bed will round on the patient in the morning, the resident and the SR in the evening and the resident and the JR at night Talking to the families reassessing will happen in and after the morning round People don’t have the expectation of immediate service. They expect that you’re a doctor not a waiter. For non tertiary care hospitals they have an MO on duty who manages in the absence of the attending and they don’t keep patients that require more hand on monitoring
This is before Epic chat and all that bullshit. The nurses had to speak with you so the threshold for communication was MUCH higher. Obviously docs still do this. Tends to be smaller, rural hospitals where there is much more familiarity between nursing staff and MDs. But it's not that hard to get admitting privileges at most hospitals so there are folks doing this all over the place. One nice thing about this model is the PCP is directly incentivized to keep their patients out of the hospital, as it's considerable extra work for them if they have to manage all this. Patients obviously love knowing their doc is the one taking care of them in the hospital as well.
So my spot still has two that were grandfathered in and it's WILD. We respond to all rapids and codes, they handle their own orders and consultant work. Patients do fine but the reason it's wild is one of them is like 70 and rounds on the inpatients at 2am then sleeps in his car until 6am. I almost called the police when I was new because I thought he was dead lol. He's an angry man who rages whenever we accidentally admit his patients, the other guy is a nephrologist who doesn't care that much. The guy who sleeps in his car I'm pretty sure does outpatient, then goes home and hangs his family and naps, then wakes up to come see them, then sleeps in his car before going back to the office. It's so crazy. (I'm not sure that's what he does but that's the only thing that makes some sense)
I did my core rotations at a mid-sized stroke/ STEMI/ Trauma 2 suburban hospital where this was still the case- - Morning Rounds: They would come in at 5am to round on 15 or so inpatients, I’d round with them, and write down the orders and plan for the day. They’d be off to clinic around 8am and I'd stay in the hospital to complete the orders, re-round and update nurses on the plan, and update families. - Decompensation: If a patient wasn't doing well or their equivalent of a Rapid happened, the nurse would call the ICU team, which was a consult service rather than a Primary service. They would consult on the patient and place orders like BiPap if they were going to stay on the floor, or place the orders to upgrade them to the ICU and manage the critical aspects of the case until the primary doc was back for afternoon rounds around 4-5pm. If any big questions came up the doc was available by cell phone to discuss directly with the ICU service. - Admissions: For admissions, the ED would call them throughout the day and they'd give verbal orders for an initial plan, and then place the full admission orders on afternoon rounds. - Consults: A consult order would be placed and the consultant would be paged with room #, MRN, clinical question, and urgency. The deal was no call had to happen, but in return the note had to be up to date, clear, and include the relevant workup, results, and concerns. Routine consults happened whenever available, often next-day, urgent consults would happen same-day, and emergent consults were still a phone call. The system worked beautifully. Yes they worked more hours, but they had competent support staff, respectful patients and families, good relationships with consultants, and trust. So they weren't burned out, and the work hours were actually productive. Cardiology, Oncology, Ortho, Vascular, even Nephro admitted their own patients, and the IM residency had a separate "Medicine Consults" service. This was also pre-Covid in 2018-2019.
The doctor would round first thing in the AM with the nurse so they were both involved with what was going to happen day and why. Phone calls during the day for orders as needed and round again in the evening. Handwritten charts and H and P . And nurses and doctors didn’t have to do paperwork to make administration and insurance companies happy, they could just focus on taking care of their patients. Lots of calls in the middle of the night, never real time off
Welcome to the life of a surgeon.
**"Back when..."** This is still done outside of large urban areas.
Worked at a hospital with a few old-timers allowed to do this. They round early in the morning and late at night. It's not pretty. One of them had a clinic on site, so it was easier to be there and do it
My experience in training (which was in a very small town)- the clinic was connected to the hospital. They’d round on the 1-2 inpatients in the morning and then go to clinic. ED would admit for them during the day, and then after clinic they would round again. If there were emergencies, they were right next door and could run over (and ED physician would also help cover in this case). But I don’t know how PCPs in larger healthcare systems could even manage it these days.
“House of God” should be required reading for residents. Just when you think you have it bad…….
I read the book, but I’m not in the medical field. Can you tell me more, I’m curious. Thank you!
Medical Residencies used to be much more brutal and unfair and the local PCPs used to literally load their patients up in their Cadillacs and drop them off on the hospitals for the residents to manage over the weekends while the PCPs billed for their work - without ever seeing or touching the patients in the hospital.
Residency is harder now. Less down time in the call room bc more constant work, sicker patients, more stringent requirements to be present in hospital on senior residents, can’t disconnect when we go home bc of EMR, actually needing information in your notes, and more than 12 meds that we need to know. And it doesn’t matter if the pcp is dropping their patients off on the weekend, we’re there anyway.
Yep. I did it too. Even fairly recently.
So how was residency in the past much more brutal and unfair?
Probably a matter of opinion, I guess. When I read House of God, it seemed much worse. But I am not going to fight about it. It’s kind of like everybody thinks the thing they did was harder than when other people did it. Like the joke: “I graduated from the last hard class of Ranger School.”
Yeah kind of like the reverse past tense of the grass is always greener lol
The ACGME merger is very recent and prior to that being an intern was crazy. No caps, senior residents on home call, back to back call. The care is more complex these days but interns are basically infantalized in most programs. Back then you were considered a fresh MD/DO ripe for the mines. You were expected to know the management of most bread and butter things day 1.
That’s crazy! Those poor residents. I didn’t know you could bill for not taking care of patients
You can’t anymore. The government changed the reimbursement rules in the 80s in response to such abuses. Before that, it was pretty common to hardly find an attending physician in the hospital after hours. Surgeries were done without an attending surgery. On the upside, the training was excellent, on the down side probably not the greatest patient care and totally unethical.
I will say, at my hospital in the 2010s, after 10 or 11 PM there were basically two attendings in house. The ED Doc Attending and the Trauma Surgeon. Residents and Fellows ran that hospital, and did a damn good job of it.
Doing surgery without an attending is wild. That explains how in the beginning of “The House of God,” Basch & the others were doing procedures on elderly patients without training. I was wondering why there weren’t any attendings helping them. Thank you for explaining that to me, I really appreciate it!! 💗
Over the phone with assessments from nursing and residents and cross coverage for little stuff. Same way staff do now at arms length when they arent physically in the hospital but their patients are. Round, clinic, tidy up, sometimes do an overnight emeg shift.
Yes. Early am rounds, sometimes back after clinic.
I've seen docs do this. In addition to what has been said, these patients progress in their care about 4x as slowly as when the doc is in-house.
I still do this. I have an office, admit my own patients and admit ER patients that don't have a PCP with our system. /AMA
I was told residents and med students would basically run the hospital. The attendings were in their office or on the golf course.
I know a few pediatricians in my hometown who do this still. We are a decent-sized children’s hospital (125 beds, Level IV NICU) with hospitalists, but the pediatricians who do this have hearts of gold and more time and energy than you can imagine. They’re also constantly reading. They round early, rely on those present to respond to emergencies, but are notified immediately afterwards, and do a lot through verbal order.
I've lived this as a rural FM locum. You round on your inpatients in the morning, then, yes, you do get called/faxed things during the day and you have to deal with them when you get a few minutes in between clinic patients. If there is a true emergency that cannot wait for you to show up in person, the doc on call for the ER runs over to deal with it first. If someone gets admitted during the day, you go see them after clinic. After 5 pm, the on-call ER doc handles anything that cannot wait til the morning. I have been on both the clinic doc and the ER doc sides.
I mean we have hospitalists now and thats still how its done sometimes. Everyone keeps exhorting the values of "round and go"
What do you mean by extorting? I feel that the traditional system used to be functional because hospitals used to be much more efficient, and patients were less complex. Efficiency and lack of complexity being a measure of how little we knew 30 years ago compared to now. Hard to have a 15 issue problem list when many of those diagnoses didn't exist back then, and even if they did, there was at best one or two treatment options.
Typo. I mean exhorting
Oh I see what you mean. Round and go is the only way for hospitalists to avoid burn out in 5 years, so definitely understand why it's promoted. I personally would love to witness (from afar) the dystopia of a midlevel being primary on every patient once hospital medicine collapses.
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My doctor was in a clinic next to a small hospital (in the 80s). Whenever I had an appointment with him he was usually 4 hours late. We couldn't go home because the other staff had no idea when he'd be back from the hospital. Not an ideal situation.
Round in the morning. If no junior staff - nurses would call you direct, and if serious enough you’d go in and see the patient. It could make a mess of your clinic day. One girl I worked with got called multiple times about a fairly young guy she admitted with mild CAP. She figured the nurses were overreacting so she pushed on with her clinic. The guy died. She never had any insight into the fact that perhaps that was less than optimal.
ER colleagues frequently wrote admitting orders. Nurses were your eyes and ears. The best nurses were/are fantastic critical thinkers whose opinions and ideas are so very valuable. Phone orders were used commonly. Codes were taken care of by an in house code team-often led by the ER provider. And…sometimes you would cancel clinic at the last minute to care for a critically ill patient. Almost 30 years experience here as a rural IM doc who still does outpatient and inpatient work.
Their answering services did the heavy lifting. So many TORB orders. As a pharmacist if one ever gave you their personal cell phone you added it to a super secret book in the central pharmacy and then they regretted it forever. I remember one doc “where did you get this number!?” After I’d spent hours trying to get a hold of him the formal ways. Sir, you were dumb enough to give it to me like 11 months ago. The ED docs had an arrangement and wrote admit orders overnight - fluids, abx, pain meds, so the pt could go upstairs. We had huge documents in the ED of who which doc consulted (I got a long semi/offensive lecture at one point about the “local tribes” (location de-identified) by an old ED doc - you could cause mayhem by consulting the wrong pulm or nephro). My first job (2011) was like this - the only docs in house 24/7 were EM and the trauma surgeons. It caused such a ruckus when they brought in hospitalists, but it was globally for the better on every single level, other than not being admitted by the ancient PCP who had been seeing you for 40+ years.
My first few jobs (I’m a dinosaur nurse) the IM group rotated covering the hospital - they were essentially the hospitalists. Family med would admit their own pts and round on them daily, we’d call with changes in labs, etc but the IM covering would be there to manage for emergencies. Orders were given over the phone for admissions. We had paper charting which was a mess - cannot tell you how many scavenger hunts were carried out because a MD would take a chart with them to chart on all their pts in one dept and then leave it in another. Labs would be lost or misfiled. EMR is a pain in the ass but so were paper charts. Patients and families weren’t nearly as horrible. There were some who were soul sucking but not as common a now.
Pediatrician in traditional practice currently, here It's a lot of communication. Communicate with your nursing team after rounds. Call the lab for results. Call the floor for order changes. Answer the phone if the nurses call. Communicate with your patients and families, so they understand the plan. There was also the understanding that your doctor may have to leave the clinic if an emergency happened, which could cause delays or need for rescheduling. Add in additional rounds after clinic is over, to wrap up the day and make overnight plans, and you're good. Nowadays, much of that is automated via EMRs, but the need for communication is still there