"This is another bullshit admission."
That's what my senior resident said while shaking her head hard. Her cheeks were pink and flushed, partly from the stairs she'd just climbed up to the ward but mostly because she was mad. Our call day had been extremely busy so far. Mostly, in her opinion, because of patients that the Emergency Department brought in similar to this one.
"What is it for?" And by "it" I meant the admission. Which kind of makes me cringe when I think of it that way.
"A man who ran out of his medications, like, a thousand years ago who now has--surprise!--a high blood sugar and blood pressure. Ugggh!" She plopped down into a chair and checked her pager. "This is the kind of thing that bottlenecks the system. It's such complete bullshit."
Bullshit. Wow. Well, if she thought it was that then it had to be just that.
See, I had immense respect for this particular resident. I was just under the halfway point of my internship and she was one of the seniors you wanted to have covering you. She was smart. She was decisive. But most of all, she simply knew what to do and always had a clear idea of how to get things done. Whether she knew it or not, she was a leader and one that I often sought to emulate.
She tossed an index card in my direction. "I have some of the information from the admission here but you'll have to check the archival for background stuff. I'd also call his pharmacy if I were you."
Oh yeah. Call his pharmacy.
"They can tell us his compliance history with these meds and exactly what he took last. Go and see him and if I can get our attending up here maybe we can discharge him before they pass the dinner trays." She laughed at that last part and I followed with a nervous chuckle of my own.
I quickly scrambled to grab the card and stood to my feet. "Okay," I responded. "No problem."
"And hurry up because we'll probably get another one soon. More bullshit from the ED, but plenty of work, still."
So down to the ED I scurried. I walked as fast as I could to get over to see this less than ideal admission--the same one that we fully intended to send on his merry way should all of the attending stars fully align.
"Hey there. I'm Dr. Draper." I reached out and shook his hand.
"Hello!" His voice was raspy with tobacco damage and his teeth beige with what was likely the same culprit.
"I came here to see you from the medical team. I heard you've been out of your medicines."
"Yes, unfortunately," he said with a tiny shake of his head. "My insurance stopped and I couldn't pay for them. So I stretched them as long as I could and then just ran out. I was hoping to see a social worker and that's it, but my blood sugar was pretty high when I got here so they wanted to keep me."
"They were checking my blood to see if I had gotten acid in it from the high blood sugar. My blood pressure was up some, too."
"Yes, sir. I saw your lab work and you don't have acid in your blood. Have you ever had what they call diabetic ketoacidosis--that is, acid in your blood from diabetes?"
"Naaaah. It's never gotten to that point. And I've been diabetic for almost fifteen years."
"Okay." I jotted that down on the card.
Next, I took an inventory of his symptoms. Chest pain? Headaches? Visual disturbances? Foot ulcers? Shortness of breath? Dizziness? I asked the whole battery of things for every body part, none of which yielded answers in the affirmative.
With his permission, I did a physical exam. Inspected his neck veins with my novice eye, placed my stethoscope onto his supine chest and closed my eyes as I left it there while listening. Maybe there was an extra heart sound consistent with longstanding blood pressure, but nothing ominous from what I could tell. I completed my assessment by pressing my finger tips into his ankles to check for any tell-tale swelling and there was none.
My resident was right. This man probably could have forgone an admission. But since he was admitted, then this probably was, as she'd so colorfully put it, "bullshit" indeed.
"Where do you live, sir?"
He described the duplex he shared with his daughter's family on the other side. That's when I learned that he had plenty of support but had just been proud about troubling anyone with his medication issues. In fact, his daughter had driven him to the hospital and had left only to get her children from school. All of it--the admission, that is--was a bit of a hassle for this man and his family. But he had decided to fully cooperate with the doctor's instructions which, this time, meant he was getting admitted.
Even if he didn't need it.
"How would you feel about NOT getting hospitalized?" I asked. I knew it was kind of bold of me to go there as an intern but I just had to know.
"Well. That would be fine with me so long as somebody could help me with sorting out my medicines." And even though this took place in Cleveland, Ohio and not at Grady Hospital in Atlanta, even then I knew that social services are often the lifeline to a solid medical plan no matter where you are.
And so. I bit the bullet and decided that I'd take it upon myself to advocate an un-admission or rather a discharge on his behalf. This meant talking to the attending physician in the Emergency Department who I'd noted to be one I'd worked with during my recent month rotation there.
I still remember that attending. He liked to be called by his first name no matter who you were and why you were calling it. In fact, he insisted upon it. This helped me to get to know him because it was very much against my medical school upbringing to call any faculty member by their Christian name. But John, as he repeatedly pressed me to call him, was a different kind of faculty. He'd had another career before all of this and it was simply his style to flatten the hierarchy. For him, that worked well and always made him a bit more approachable and fun to work with. Plus he was middle-aged with graying hair so the whole first-name basis never seemed to undermine his authority in any way.
Anyways. I went over to where he was and found him talking to one of the upper level ER residents. Since he was such a nice guy, he immediately smiled when he saw me. "Welcome back, Kotter!"
I chuckled at that goofy 1970's reference and replied, "Hey there, John. How are things going?"
"It's the emergency department. Things are always going!" He passed a chart back to the resident in front of him. I loved the way he always made things look so relaxed and easy. "Is everything okay with you?"
I was glad he gave me an opening to talk about my patient. The attending who'd seen him earlier was now off of her shift so all of this would be brand spanking new to John. And so I carefully discussed this man and his lack of insurance which led to his lack of medicines and blood sugar and pressure control. John listened intently and nodded his head with each layer to the story. I also noticed the body language of that upper level resident. Her arms immediately stiffened and a ripple of discontent rolled over her face the minute I said the name and room number.
"So, do you think we can get him a definite game plan for follow up?" John asked.
"I feel certain that if I hustle right now, I totally could." I felt my pulse quickening. He was listening to me--the intern--for real listening to me. Hearing the story and trying to make sense of it. I couldn't wait to head upstairs triumphantly to tell my resident that I'd officially "blocked" my first admission.
A "bullshit" admission, no less.
"I will go and see him again. I can't see why that should be an issue," he said while staring at an EKG tracing. Then he looked up at me and smiled. My face felt warm because as interns it wasn't every day that your voice felt so heard. John always had a way of doing that with every single learner, nurse, patient and person around him and I could tell, even then, that it was a decision that he'd made long ago.
And so. John and his senior resident disappeared behind the door leading to that patient's room. A few moments later they returned and confirmed that our man with his missing medicines would indeed go home and return the following day for follow up in the clinic.
I nodded and quickly paged my resident. As soon as she called back I proudly told her of how this patient--the "bullshit" admission--was an admission no more. And she patted my back as best she could through the phone and affirmed me for a job well done. I was over the moon.
Just as I hung up the phone, I saw John walking in my direction after finishing with his senior resident. I stood at attention to be sure my body language signaled deference. "Hey, can I do anything?" I asked.
"No. . . . he said, but I do want to give you some advice." His voice was decidedly serious and it kind of made me nervous. He pointed at his chest and then at me. "Us, all of us, are in this thing together. Our goal is to do what's best for the patients and nobody wins when we're more interested in ourselves than our patients."
Ooooppph. That kind of hurt. I felt a lump developing in my throat. Had I acted too elated when I'd learned that the patient wasn't being admitted? Perhaps I had since that's exactly how I felt.
"Kim, your resident was rude and confrontational. She is passionate, yes, but was proud. Too proud to have a conversation that felt collaborative for the patient. I heard you when you called her and was a little disappointed to hear what you said."
My mouth fell open. Which part had he heard?
He put me out of my misery. "You said, 'The BS admission is OTD.' (OTD = out the door) And, Kim, that was not only insulting to my resident, but to my department." I felt my eyes stinging with embarrassed tears. I coached myself not to cry while holding his gaze. "You know, Kim, that gentleman was one that deeply concerned my resident. She was afraid that he'd fall through the cracks and had noted two other times that someone had tried to manage him as an outpatient. She'd given thought and consideration to that decision and hearing it all referred to as, well, 'bullshit' was a little offensive. And surprising coming from you since we'd worked together before."
"I'm sorry, John." My voice was thready and anemic, which made sense considering I felt like all of my blood had drained down and pooled into my feet.
"Your resident doesn't realize her power. You see, I've worked with her and she's a good doctor and leader. And you know? I see a leader in you. A real, true leader. But always remember, Kim-- we have to be good stewards of our influence. We must."
And John left it right there. Left me with that deep statement to ponder and chew upon for the rest of the day and perhaps, my life. I never, ever forgot that lesson. Not ever.
That patient did well and, though I'm not fully sure where she is, I imagine that my resident did, too. But this morning I was just reflecting on that sage advice that John, the attending-on-a-first-name-basis, had given me nearly sixteen years ago.
"We have to be good stewards of our influence. We must."
And so I think of this. I think of this when I talk to people in hallways and when I get dressed each morning. I remember how John knew the names of the custodians and how he bought Diet Cokes for nurses and interns on his way to the vending machines. But most of all, I remember the way he spoke of the patients. Almost always in a collaborative spirit and rarely, if ever, in anything else.
Collaborative with his learners. Collaborative with consultants. Collaborative with nurses and pharmacists. Collaborative even with the people passing trays from the cafeteria or the person emptying a waste basket. But especially collaborative with the patient. Which matters most of all.
I still appreciate that feedback and him telling me directly that he saw me as a leader. It was a pivotal moment for me and is one I return to regularly.
So today and every day, my intention is to be a good steward of my influence. Some days, I get it right. And the other days? It's a work in progress.
Now playing on my mental iPod. . . . some old school New Jack Swing for you--Guy singing "Gotta be a leader."
. . and some Eric B. and Rakim. . . "Follow the Leader." That's the jam!