Unattended Patients: first week in Nebraska

What will the hospital do,

To equally assign to the crew

And not hurt the workers

Who make up for the shirkers

Who dodged the call that they drew

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a funeral, a bicycle tour in Michigan, cherry picking in Iowa, a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia.  Right now I’m in western Nebraska.  Any patient information has been included with permission.


Sometimes, people who don’t have a physician, or who don’t have a local physician, need hospitalization.  As time has gone on, I’ve seen shifts in the way that hospitals approach the problem.  Every hospital where I’ve worked made privileges contingent on willingness to care for those patients on a rotating basis.

The move to staff hospital ERs full-time started in the 70’s, and I can remember a very good ears-nose-throat specialist putting on a set of scrubs to take the night-time duty.

In residency, the ER doctor would open up a box containing 3×5 cards with the name and phone number of every primary care doc in town, take the card at the front, call the doctor in question, and move the card to the back of the box.  We referred to those patients as “box calls,” and OB had a separate rotation.  Some docs took the system with more equanimity than others, and, as always, the workers resented the shirkers.

When I came into private practice, both hospital ERs maintained a list on the bulletin board next to the emergency doctor’s work station.  He or she would make the call, and cross the name off the list when the doc in question accepted the admission.  We called it the “hit list.”

Those patients rarely had insurance or money.   I did for free most of the care in that system, and I regarded the financial loss as part of my social obligation to do some pro bono work.  Other docs didn’t see it that way, and some invariably had a reason to dodge the hit.  I did my best to be pleasant on the phone to the other doc.  I established a good rapport and a good rep, but about every 7 years, when very tired or overloaded, I’d use my past cooperation to delay till daylight the next hit.

Those two institutions have since moved to a system where the ER doc makes the decision to admit, and the hospitalist employed by the hospital attends the patient during their stay. Fewer and fewer primary care doctors attend patients in the hospital. Alone among first-world doctors, US physicians have the option to do both inpatient and outpatient work.

Here in western Nebraska, where our critical access hospital has a staff in the single digits, I agreed to take care of the unattended admissions (here called the “no docs”).  I suppose that makes me the de facto hospitalist.  I resolved to be the best of the breed, and, if the patient has a physician out of town, to make a doctor-to-doctor call at discharge.  At the end of my first week here, I met the goal 100% of the time, in numbers barely into the plural range.

I have gotten comfortable with the inpatient EMR, I still don’t have access to the outpatient EMR.  Midweek we moved into a very nice town home outside of town with a lake view.  I face a 14-minute commute, unless I go slow enough to admire the scenery.


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