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I'm a relatively new attending in my first year out (did a fellowship last year with some moonlighting, but this is my first big boy job). I, like many new attendings tend to be on the more conservative side. At least once or twice on a shift, you get that patient that you know is going to be a soft admit, but you don't feel comfortable sending home. It sort of builds up over the next few hours as you prepare for the inevitable dreadful battle with the hospitalist, and sometimes I (regretfully) end up hoping I find something so I can keep them in the hospital. It's not that I have an issue discharging patients, but it's just that some people give you a high risk story, or have risk factors, or just look terrible despite what their numbers show. Sometimes, I just want them to be watched for awhile, but I know it's a soft admit and I'm going to get reamed by the hospitalist.
We really live by a doctrine of ensuring outpatient follow up for our patients. Well, if it takes 6 months to get in to see a cardiologist for a chest pain workup, I don't feel comfortable sending them home to just wait it out.
I really dread these "low risk" chest pain patients. At my hospital I have a hard time coordinating outpatient follow up for them. They say all the bad things. They have all the risk factors. But sometimes they lack objective data i.e. EKG changes or enzyme leak etc. Pitching these patients to the hospitalist is a nightmare, and I hate the phone call. "They have two negative troponins and a unchanged EKG, what are we going to do for them in the hospital?" or "They presented for the same thing 2 months ago and had a negative workup." These points and questions are valid on part of the hospitalist, and I do think avoiding unnecessary admissions is a good thing. HEART scores, while I love them, IMO seem very conservative and probably lead to many unnecessary admissions and stress tests. But I think my risk tolerance is exceedingly low, and when patients are old, or tell a good story, I just get nervous and err on the side of wanting to keep them. I'm not particularly proud of this, and don't think it makes me a great doctor, and sometimes I feel like a wuss.
2 nights ago I had a patient: 83 year old male, history of atrial fibrillation not on anticoagulation. Syncopized in the kitchen while cooking, broke his mandible on the kitchen counter. EKG just revealed atrial fibrillation (rate controlled). Troponin was negative. He just looked terrible. And he looked old. And I didn't have a reason for why he syncopized. His CHADS-2 score was 3. He was recommended by cardiology years ago to start anticoagulation, but for some reason, never did. He just looked awful, and I wanted to keep him despite any objective data, he seemed like a high risk person to me, and the hospitalist was having none of it.
My admits are probably overkill, and I fully concede that. But how do I become less conservative? Is it just time? How do I not get that patient that I am going to dread calling the hospitalist the entire time? I want to be a good steward of healthcare resources, the hospitalists time, etc but I also want to sleep at night. All of these things seem to be at odds with each other.
We really live by a doctrine of ensuring outpatient follow up for our patients. Well, if it takes 6 months to get in to see a cardiologist for a chest pain workup, I don't feel comfortable sending them home to just wait it out.
I really dread these "low risk" chest pain patients. At my hospital I have a hard time coordinating outpatient follow up for them. They say all the bad things. They have all the risk factors. But sometimes they lack objective data i.e. EKG changes or enzyme leak etc. Pitching these patients to the hospitalist is a nightmare, and I hate the phone call. "They have two negative troponins and a unchanged EKG, what are we going to do for them in the hospital?" or "They presented for the same thing 2 months ago and had a negative workup." These points and questions are valid on part of the hospitalist, and I do think avoiding unnecessary admissions is a good thing. HEART scores, while I love them, IMO seem very conservative and probably lead to many unnecessary admissions and stress tests. But I think my risk tolerance is exceedingly low, and when patients are old, or tell a good story, I just get nervous and err on the side of wanting to keep them. I'm not particularly proud of this, and don't think it makes me a great doctor, and sometimes I feel like a wuss.
2 nights ago I had a patient: 83 year old male, history of atrial fibrillation not on anticoagulation. Syncopized in the kitchen while cooking, broke his mandible on the kitchen counter. EKG just revealed atrial fibrillation (rate controlled). Troponin was negative. He just looked terrible. And he looked old. And I didn't have a reason for why he syncopized. His CHADS-2 score was 3. He was recommended by cardiology years ago to start anticoagulation, but for some reason, never did. He just looked awful, and I wanted to keep him despite any objective data, he seemed like a high risk person to me, and the hospitalist was having none of it.
My admits are probably overkill, and I fully concede that. But how do I become less conservative? Is it just time? How do I not get that patient that I am going to dread calling the hospitalist the entire time? I want to be a good steward of healthcare resources, the hospitalists time, etc but I also want to sleep at night. All of these things seem to be at odds with each other.