Russ Cucina, MD, MS, a hospitalist at the University of California San Francisco (UCSF) Medical Center, and a colleague once spent a week wearing pedometers on the job to study how much ground they covered in the course of managing their patient caseloads in a huge hospital like UCSF. The result: an average of four miles walked per day.
“The usual productivity infrastructure for physicians in their offices is simply not as available to hospitalists, or isn’t under our control,” Dr. Cucina says. There may be networked computer terminals throughout the hospital, but how many there are, how accessible they are, and how much competition there is for them varies. Hospitalists may have their own offices, desks or shared office space, depending on institutional commitments, but these may be a trek from patient care areas.
As a result, they must bring essential tools of their trade on their persons. Some carry a briefcase or wear a fanny pack, but more often these essential tools are stuffed into every available pocket of their medical lab coats.
Dr. Cucina’s short list of essentials is typical of working hospitalists. It includes his “smart phone,” combining a personal digital assistant (PDA) and cell phone, pens, a reflex hammer, a tuning fork for testing neurologic sensitivities, a stethoscope, swabs for sterilizing the stethoscope, a stash of large hospital gloves (which can be a hard size to find), and a bulky and awkward—but secure—prescription pad in a cardstock wrapper.
He also totes a stack of 3-by-5-inch index cards held together with a steel ring—one card for each active patient, updated daily by hand with medication changes, lab results and other information provided by the residents. “I have tried higher-tech approaches,” he explains. “I am the hospital’s associate medical director for information technology, and I need to keep up to date and try new things, including the various applications for keeping patient lists on line. But nothing has yet beaten out hand-written index cards for efficiency and ease of use. The time it takes to input this information electronically just isn’t worth it.”
Hospitalists say additional medical tools, such as an otoscope or ophthalmoscope, could be helpful but may pile on too much bulk and weight. “I’m often challenged to find one on the floor when I really need it,” Dr. Cucina says. Portable scopes are also quite valuable and at some risk for disappearing from an unattended lab coat in the highly trafficked hospital setting.
PDA Is No Panacea
For many hospitalists, one key to efficient mobility on the job is the PDA or laptop computer, with basic references such as UpToDate, Epocrates, Tarascon Pocket Pharmacopoeia, or the Washington Manual of Medical Therapeutics, either loaded or accessed via the Internet. PDAs involve serious compromises balancing size and weight with ease of keyboard use, ease of reading the screen, and memory or processing speed. (See “Tackle Technology,” November 2007, p. 22 for a discussion of how hospitalists use portable computing devices on the job.)
“We’ve come a long way from tongue depressors and otoscopes,” says William Ford, MD, program medical director for Cogent Healthcare’s large and expanding hospitalist group based at Temple University, Collegeville, Pa. “Some of us at Temple, depending on the service, carry one or more cell phones and between one and three pagers, in a pocket or attached to a belt.” The doctors may have their own PDAs, but Cogent no longer supplies them, having converted to a Web-based tool that offers a variety of practice management resources accessed by laptop computers via the Internet.