Returning to the Hospital, 15 Years Later

I spent the first hour of my first hospital shift in 15 years trying to log in.

As a middle-aged internist, I’ve spent my clinical career since residency practicing outpatient primary care. But as happens in midlife, over the past year multiple family members and friends were hospitalized. Sitting at their bedside—watching the extraordinary expertise and kindness of the physicians, nurses, and other healthcare professionals caring for them in moments of real need—I found myself drawn back to hospital medicine.

As the first person in my family to become a doctor, I grew up imagining that I would care for families through whatever life threw at them—at home, in the community, and, when the time came, in the hospital. But during training, I learned that just as medicine divides the body by organ system, it also divides itself into outpatient and inpatient care. Forced to choose, I chose primary care—for the chance to know families over time, and to prevent disease before it happened.

The last time I had worked in a hospital was as a senior resident at a busy urban academic center. I belong to the generation that went from rotary phones and pay phones to cell phones, from no internet to wireless everything. I also belong to the generation of doctors that went from rounding with paper charts and reading vital signs aloud to practicing in a fully electronic health record, with digitized order entry and e-prescribing.

So after a year or two of debating whether to return to hospital medicine, six months of credentialing, and weeks of final logistics—getting a hospital ID badge, being fitted for a respiratory mask—I was beyond excited for my first day. Given how long I’d been away, the hospital assigned me a fellow hospitalist to shadow, someone who had just finished residency.

When I arrived, I was thrilled to find we already had two holdovers—patients who had come in overnight but had not yet been staffed by a hospitalist. My first instinct was to run down to the ER, find out what was wrong, and start putting together orders. I quickly learned that is not how the workflow usually goes. First we log in, pull up the patients, put in temporary orders, and even start a preliminary note—before seeing them.

After successfully logging in, I learned my electronic health record account was blocked. So while the patients waited downstairs, the first thing I did was call the IT help desk. A bad omen.

When the chart finally opened, I was met with such a dizzying array of colors and numbers that I’m surprised it didn’t trigger one of my migraines. I had used the same system 15 years ago. It had been a long time—but somehow the screen had become even more cluttered.

As I started reviewing the patients, I found myself increasingly eager to go downstairs. Then I overheard my colleague dictating into the computer. As she reviewed a patient’s history, she narrated her note in real time—a time-saving maneuver that, given the number of patients she carried, was not so much a shortcut as a necessity. Still, it gave me pause: to first hear about a patient from the medical record, rather than from the patient.

A defining moment came a couple of hours into my shift. One of our patients was feeling better and insisting on going home. According to the nurse, he felt it was his right to refuse medical care and was threatening to leave against medical advice. With a full slate of patients to manage, my colleague first messaged the nurse to relay her concerns. When that didn’t work, she called the patient’s room and spoke to him by phone. Only when it became clear he still could not be convinced to stay did we go in together.

The moment we walked into his room, clinical intuition kicked in. It was obvious from the doorway: he was not angry. He was scared. He had recently been diagnosed with metastatic bladder cancer, had undergone surgery, and was receiving chemotherapy. Over the previous few days, he had developed worsening congestion and cough. A CT scan showed a small pleural effusion, and an echocardiogram obtained during the workup revealed not only the effusion but significant global left ventricular dysfunction. Now, in addition to metastatic cancer, he was being told he had heart failure.

He was frustrated that his body kept failing him. Overwhelmed by what it all might mean. Once we explained the situation—what we thought another day in the hospital could accomplish—his posture softened. “Well, okay then,” he said. “I guess I’ll stick around.”

The medicine itself was incredible. In a single day I saw more pathology than I typically encounter in a year of outpatient practice: new-onset heart failure, a new diagnosis of metastatic adenocarcinoma, a malfunctioning G-tube, hypercarbic respiratory failure, hypertensive urgency.

But for all the medicine, we spent surprisingly little time with patients. Over ten hours and nine admissions, I would estimate we spent less than 45 minutes at the bedside. The rest of the time was spent mostly in the workroom—reviewing records, documenting notes and orders, messaging nurses or consultants, or talking on the phone.

Some parts of care had clearly improved. One patient, being treated for cancer at a major academic medical center, happened to be visiting family in the area when his G-tube stopped working. With a few clicks, I could access all of his outside records from an institution more than a hundred miles away. A far cry from the hours once spent faxing record requests and pleading with clerks. Computerized order entry, too, had become almost seamless—within minutes of placing an order, pharmacists were messaging back with suggested dosage adjustments based on kidney function and current medications.

I also found the messaging feature genuinely useful, if imperfect. Instead of paging someone and waiting for a callback, we could communicate fluidly—which meant we actually communicated more, because the friction was lower. But at times, that very ease made messaging the default, even when something more direct seemed called for.

At one point, we went to see a patient admitted for hypertensive urgency. The moment I walked in, I noticed she had no blood pressure cuff and no telemetry. I moved toward the intercom to call the nurse, but my colleague waved me off and continued the history and physical—she knew the chart, knew the patient was likely stable, and was making a reasonable clinical judgment. But when we stepped out and I suggested we find the nurse to get the monitor back on, she said, “Oh, no need—I’ll just message her.”

There was nothing wrong with that, exactly. But it captured something about how the culture had shifted—not through any one person’s failing, but through the slow accumulation of a thousand small efficiencies that had made the screen the default medium for nearly everything.

With so many doctors involved in each case, it was never entirely clear who was accountable for the whole patient. In theory it was us—the hospitalists, as the treating physicians, coordinating care and consulting specialists. But in practice, we often accepted specialists’ recommendations without question and seemed collectively hesitant to address anything beyond the immediate reason for admission—whether out of deference to the PCP, to specialists we had not yet consulted, or to our own narrow role in the long arc of a patient’s care.

One patient with coronary artery disease and a stent was on a moderate-dose statin when she should have been on a maximum dose, but we did not change it. Another had been admitted for a COPD exacerbation and was still actively smoking. It was not until I suggested a nicotine patch and spent a few minutes counseling him on quitting that anyone addressed the root cause of why he was there in the first place.

No single doctor was to blame for either gap. The system had simply made it easy—and in some ways logical—for everyone to own a piece, and for no one to fully own the whole.

By the end of the shift, I kept thinking that we were less doctors on a ward than air traffic controllers at a console—managing the machine from a distance, moving patients through the system with technology as our primary instrument. My colleague was wonderful, and that is partly what made the observation feel structural rather than personal: these were the conditions she had inherited, the workflow she had been trained inside. The system had been optimized for throughput, and she had been optimized for the system.

But in my experience as a primary care doctor, medicine at its best is something messier and more human than that—a place where numbers have to be weighed against what you see in someone’s eyes, and where patients are scared, complicated human beings who need more than orders and prescriptions. They need someone to help them understand what is happening to their bodies, and to coach them toward the kinds of healthier behaviors that might keep them from getting sick again.

So much had changed in 15 years. And yet some things had stayed exactly the same: the camaraderie in the workroom, overhearing colleagues talk about buying homes or pregnancies or battles with insurance companies; the dedication of the nurses; the professionalism of the consultants.

But most of all, the patients.

Our last patient of the day was in his early forties. Just two months earlier, he had been diagnosed with cholangiocarcinoma. Since then, he had had his entire colon removed, endured multiple drainage complications, and lost a significant amount of weight. He was in the ER, in pain and short of breath, with his elderly mother at his side. He repeated his story for what must have been the umpteenth time that day. And when we turned to leave, he tried to stand to thank us, before his telemetry wires and exhaustion held him back.

The gesture nearly brought me to tears. I had not taken care of a hospital patient in 15 years. I was there as an observer, still finding my footing. And yet the moment I walked in, I was accepted—without hesitation. That kind of access to people’s most frightening, most vulnerable moments does not come from experience. It comes from two letters after your name. It is an extraordinary privilege, and one that is easy to forget when you live inside it every day.

I can only hope that 15 years from now, when all this is old again, I remember that—and that I fully own the awesome responsibility that comes with it.

—Shantanu Rai