Coat Tales

The Hospitalist. 2008 August;2008(08):

August 1, 2008 | The Hospitalist

Love/Hate Situation

Dr. Cucina uses an online custom supplier of medical lab coats with extra, zippered pockets on the inside and outside. He’s careful not to let the lab coat of out his sight when he takes it off.

Randy Ferrance, MD, a hospitalist in internal medicine and pediatrics at Riverside Tappahannock Hospital in Tappahannock, Va., acknowledges his own love-hate relationship with the lab coat. In his pockets, he carries a stack of 3-by-5-inch index cards, an 8.5-by-11-inch hospital census sheet, folded over, a prescription pad, a highlighter pen and spare pens, the ubiquitous stethoscope, an EKG caliper, a reflex hammer with microfilament test for diabetes, and a pocket Sanford Guide.

“I’d love to ditch the lab coat,” Dr. Ferrance says. “I often take it off when I sit down and sometimes end up leaving it behind, such as in the medical dictation area. I never want to wear one when I’m talking to a child. But for a lot of families of patients who are critically ill, it is a symbol, almost like the armor of the knighthood of medicine. You have to read each family, but for some, you lose credibility when you take it off. They’re looking for everything that medicine can offer, and the lab coat gives them more confidence in you.”

Dr. Ferrance appreciates the smaller size of his 47-bed hospital, where he is never a long walk from anyplace. He frequently returns during the day to his office, which he doesn’t have to share with other doctors. He uses it for family conferences and to store larger manuals, his laptop, and diagnostic kits.

He also values his Treo Smart phone, which incorporates a variety of programs, including a drug reference, billing program, lab reports on active patients, pediatric growth chart program, pneumonia severity index calculator, a medical calculator, Geriatrics At Your Fingertips, the Harriet Lane Handbook: A Manual for Pediatric House Officers, the American Association of Pediatrics’ Redbook comprehensive online infectious disease resource, hospice eligibility criteria, a camera—“to take pictures of odd lesions”—and access to e-mail and sports scores.

Although a briefcase is one more thing to lug around and risk losing, Julia Wright, MD, director of hospital medicine at the University of Wisconsin Hospital in Madison, says she carries a bag that is a woman’s version of a briefcase, with her laptop and active administrative files required for her growing administrative duties as director of an academic hospitalist group.

“There are advantages to being mobile, but disadvantages as well,” Dr. Wright says. “You just can’t get everything done. I get between 50 and 60 phone pages a day, and a lot of curbside consults, as well.” The medical center is restructuring teaching services so a hospitalist’s assigned patients would be more often concentrated in one area, with less running from floor to floor, as well as exploring new office facilities for the hospitalist group.

Currently, 11 University of Wisconsin hospitalists share a room with five cubicles. “I’ve put my pictures up on the wall anyway, and I keep my files, stapler, and office supplies there. A couple of my partners keep their reference books there. What I like about sharing space like this is it can help with communication and collegiality within the group. We do a lot of patient hand-offs there. But as we grow and it becomes more crowded, we’re going to need some more dedicated space.” TH

Larry Beresford is a medical writer based in California.

The Hurdles of Mobility

The mobility required of the working hospitalist can be a big hurdle to overcome, suggests David Grace, MD, area medical officer for the Schumacher Group’s Hospital Medicine Division and a hospitalist at Southwest Medical Center in Lafayette, La.

“I don’t like to carry anything in my pocket but keys, pager, cell phone, and patient list,” Dr. Grace says. “But I also need to carry a stethoscope, a penlight, a few pens, which are always getting lost, and a few laminated emergency reference cards, such as advanced cardiac life support protocols. I’m a firm believer that anytime I run a code, I need to stand there and go right down the checklist.”

The mobility challenge, Dr. Grace says, reflects the lack of standardization of protocols, forms or prescription order entry in the hospitals where he works. “So you still need paper progress notes and order sets. If you are mobile, the stack gets bigger and bigger. Unlike emergency physicians, who have access to stacks of paper, we carry these things in our pockets.” Dr. Grace wonders if there is a way to improve the capacity of doctors’ lab coats. “I’m looking for one with more than two outside pockets, but I don’t want to walk around in something that looks like a fly-fishing vest.”

He carries a Blackberry, which combines the functions of two previous PDAs, a cell phone and pager, although there are limits to what he can do on its small screen. A networked laptop would lack the battery life to get him through the day, with variable Web access at the hospitals where he works. At one facility there is only one Web-based computer terminal per floor for physicians to use. “Not long ago, I saw a patient with a very unusual condition, which only six people on earth have, and I found rarediseases.org to be invaluable.”

Sometimes hospitalists work without any office space at all, Dr. Grace notes. “We have a small office here in the radiology department, next to the emergency department. The hospitalists share desks, which are small but workable. Years ago, when I worked in Phoenix, we didn’t have any designated workroom. You parked your car in the hospital parking lot, walked in the door, and you were on your own. Even now, if I need to make a private phone call, it’s hard. Sometimes I go out to my car to make sensitive calls.”

Another problem he notes is that the patients can be mobile, too, moving from the operating room to dialysis or X-ray. “Just finding your patient can be a challenge sometimes. ‘Oh, Dr. Grace, you just missed him, he’s in X-ray.’ I can ask the nurse to call me when the patient gets back to the floor. But they get tied up, and by the time they call, the patient’s gone again. Sometimes, the only place I can see the patient is in X-ray.”—LB