My Love-Hate Relationship With Hospitals

Craig R. Hildreth, MD

After a long session of office hours the other day that can be best described as an amateur rendition of a three-ring circus, while silently clicking through the clutter of electronic charts crowding my screen, I had a strange epiphany:

Hospitals are making it more difficult for me to get my work done.

An atypical thought indeed, but before I even had a chance to debate this notion I felt a sudden twinge, like the last day on a job after giving notice. The more I considered this, though, the more evidence I found to prop up this disgraceful attitude. Of course it is ridiculous to ignore the importance of hospitals. Hospitals are in the business of amelioration, and they are masters at it. It’s just that my individual contribution to the goal of helping people get rid of or survive cancer takes place in my office, so every time the hospital summons my presence, the mission grinds to a halt.

Recall that the bulk of a doctor’s training is done inside of hospitals. Back in the day, after getting over the sheer terror that like quills upon the fretful porpentine shocks innocent interns, many of us (see: Stockholm syndrome) came to love the bustle and drama of the daily inpatient routine as much as we grew to cringe at the drudgery of the outpatient clinic. Now after two decades in private practice my affections appear to have reversed-I relish my office hours and approach hospital rounds like an army ranger ordered to infiltrate Stalag 17. What happened?

For one thing, patients need access to their oncologists, and in my practice the office is the place where the twain shall meet. From the moment I stumble through the door until my secretary turns the lock at five o’clock, I am available to anyone who crosses my threshold. True, it is an inconvenience for patients to have to come to me, but once here they have my undivided attention whether they have an appointment or not. The easier it is to reach your oncologist, the smoother the clinical course runs, and if I’m not in the office the silence is deafening. With the rise of hospitalists I don’t have the same responsibilities for inpatient care as before, and with the launch of the electronic medical record I can monitor folks 24 hours a day. Both of these advances serve as a disincentive to spending all morning driving from one hospital to the next to find out what is going on when I already know what is going on and what is being done to remedy it, while in the meantime my waiting room becomes a testing zone for the limits of patience, if you know what I mean.

As an independent oncologist, I deliver the daily beating to various surly malignancies in my treatment room. Most modern day chemotherapy and biological regimens do not require an inpatient stay; therefore the more patients are sequestered in the hospital the less likely they are to get on with their treatment. As for oral agents, they are convenient until hospitalization, at which time we often discover that the needed drug is not on formulary.

I would say that this is the antithesis of the science of tumor kill, n’est-ce pas?

Then there are oncology nurses. They are admirable professionals and each day I expect them to give their best effort to the cause. My office nurses, however, have an advantage over hospital nurses-I sign their paychecks. Yes, when it comes to building a mighty team, there’s nothing like being the general manager and franchise owner to energize the players.

In the office there are also fewer time constraints. I’m here all day, so fire away with your questions-you won’t be subjected to the traditional hospital peek-a-boo visit that was immortalized by Sir William Osler rolling over in his grave.

Your oncologist may be the smartest in the nation, but if you do not understand what the diagnosis, treatment, side effects, prognosis, and follow-up are, you might as well hire “Dr. Google” instead. We must always do our best to deliver the information patients need, and when it comes to effective communication, there is no competition: the office wins again. You try explaining the arcana of dual HER2 receptor blockade to a hospital patient while the aide is taking their blood pressure, the IV pump is beeping, the transporter is waiting in the hallway, and the internet firewall won’t let you pull up an educational brochure. In the office we have nothing but peace and quiet, plus my laptop with access to oodles of material for your amusement-how about a juicy diagram of the RAS/RAF/MEK/ERK pathway?

If you follow the news these days you might have read that the private practice of medical oncology is either dead in the water or encircled by menacing fins. This is a crying shame; however, I must confess that if my office is ever reduced to shark bait I most certainly will, hat in hand, go merrily begging for a job. After all, who says we private docs can’t adapt to those big, scary places called hospitals, not to mention help to transform them into a workplace as exemplary as the one we hold such fond memories of?