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In this episode, we dive into the physician-nurse relationship and explore the different communication styles and preferences of physicians. Our guest, Ronald Hirsch, is a medical director for case management at a community hospital and shares his insights as a physician on things that nurses should know when communicating with doctors. From tips on writing narrative notes to understanding the pressures and workloads of physicians, this episode is for anyone working in the health care field. Join us for an honest and informative conversation on improving the physician-nurse relationship.
Ronald Hirsch is an internal medicine physician and can be reached on Twitter @signaturedoc.
He shares his story and discusses his KevinMD article, “Physician secrets that nurses need to know.”
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Transcript
Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today on the show we have Ronald Hirsch. He’s an internal medicine physician. His KevinMD article is titled “Physician secrets that nurses need to know.” Ronald, welcome to the show.
Ronald Hirsch: Thank you. Pleasure to be here.
Kevin Pho: Oh, thank you so much for joining. We were talking about one of your past articles, back in 2016, about the opioid epidemic. It still resonates today. Now, we’re going to get into the article in a little bit, but first off, just briefly share your story and journey to where you are today.
Ronald Hirsch: So, as you mentioned, I’m a general internist. I also had an HIV specialty. I was in practice for 21 years in suburban Chicago. In 2006, the hospital was looking for a physician advisor, and they thought that I would do well at the job, so they asked me to do that part-time. That has developed into a full-time career where I’m now working for a revenue cycle company, helping hospitals with their physician advisor programs, level-of-care determinations, etc.
Kevin Pho: So walk us through a typical day of what you do, because I think that one of the themes that I have on my show is that physicians are more than our degrees. We’re certainly more than seeing patients, and we like to investigate other avenues, and yours right now is a nonclinical role. So tell me about a typical day. What kinds of things do you see?
Ronald Hirsch: Well, my days are very atypical because of my position with my company, but what I do is I read Medicare regulations. So when Medicare puts out a new proposed rule, you know, 1,000 pages, 3,000 pages, I read it through and see how it would affect the hospitals that we work with. I provide them education and provide comments to Medicare. In the next hour, I’ll be doing a webinar for our clients about the Medicare inpatient-only list. I work with hospitals, training their doctors to understand medical necessity, NCDs and LCDs, and all the regulatory stuff that no one teaches us in medical school.
Kevin Pho: Now, how did you learn all that regulatory stuff? Because you were in clinical practice for about 20 years, and now you’ve made this transition into a regulatory role. Did you have additional training? How did you learn how to do this?
Ronald Hirsch: I had a little bit of training, but honestly, it was mostly going out there and finding stuff, going on the internet, reading. There are discussion groups. Now, actually, I co-authored one of the textbooks on hospital utilization review. But it was really just picking it up by osmosis: reading, asking, researching, figuring it out.
Kevin Pho: And for those clinicians interested in an opportunity like what you’re doing now, what kind of advice can you give them to get involved in something like this?
Ronald Hirsch: Well, I’m part of a nationwide organization called the American College of Physician Advisors, and it’s got hundreds of physician advisors from around the country who have joined. We’re pooling our resources together. There are all kinds of educational modules, webinars, reading material, newsletters, etc. So I think that’s a good place to start.
Maybe even a step back, if you’re interested in the administrative side of health care, is getting involved with your hospital committees. Serving on the UR committee, the medical records committee, you’ll kind of get a peek behind the curtain on what happens in hospitals.
Kevin Pho: All right, so let’s talk about your KevinMD article, titled “Physician secrets that nurses need to know.” Now, how did this article come together?
Ronald Hirsch: Well, part of my work at my community hospital was to orient the new hospital staff, the nurses, the dietary aides, etc., to kind of the regulatory side of medicine. At the time, I was still a practicing physician who took care of hospitalized patients and office patients. I thought, “Here we have these brand-new nurses coming into the hospital.” They just finished their education, and they’re coming to a community hospital, which is probably different from the world that they were trained in, a teaching environment.
So I thought, “Let me put together some points to talk to the nurses about when they communicate with physicians, what they should keep in mind.” Again, they’re used to working with residents and interns and fellows, where there are always doctors around. But in a community hospital back 10 years ago, and even today, there are still hospitals where there are community doctors who round in the morning, run to the office, see a bunch of patients, come back to the hospital, go home, spend time with their family, and have to get up every morning and repeat the same thing.
So I thought, “Let me give the nurses some perspective on what these doctors are going through, what their life looks like,” so when they communicate with them, when they interact with them, they can understand it from their point of view.
Kevin Pho: So give us some examples of some of the anecdotes and tips that you wrote in your article.
Ronald Hirsch: For example, “When I’m on call, I cover four hospitals and 60 patients.” So often you have a nurse calling at night to the pulmonologist who’s covering for his whole group or her group, and they don’t remember every single patient. They may have gotten sign-outs, but they really count on that nurse to portray the clinical picture so they can understand how they can help that patient at the time.
“I’d rather give a patient their opioids than confront them” was something I put in this list years ago, again understanding that the opioid epidemic is a problem and it’s a tough situation for doctors to be in.
Here’s one: “I like to teach, so ask me to explain, but don’t question my authority.” There’s a fine balance between doctors wanting to share their knowledge and being told what they have to do, so understanding that.
“I want my patients to eat meals in a chair.” That was one I always stressed with my patients who were in the hospital. It’s very easy for patients to get in the hospital and spend their whole day in a bed. Remember, get them up for meals at a minimum. That’s going to speed their recovery tremendously, so reminding them of that kind of importance.
There’s one here: “I like to practice evidence-based medicine until the evidence differs from what I’m doing.” That’s a little bit more of a controversial one, but oftentimes nurses will hear things, they’ll learn things, and then they’ll see it done differently. Why is it being done differently? Is it the physician with their own practice style? Are we doing what’s right for the patients?
Again, as a physician advisor, one of my enjoyable roles was that the nurses knew who I was and what my role was. So rather than, quote, confront a doctor about why they’re doing something, why they’re ordering a test, the nurses could come to me and say, “Can you help me understand why Dr. Smith ordered this CT scan? It doesn’t seem to fit why the patient’s in the hospital.” And I could use my medical knowledge, review the chart, and help them understand the patient’s treatment course. Maybe it would lead me to talking to Dr. Smith and saying, “Why are you doing this CT scan? Can we wait until the patient’s gone home? Let’s spare them the CT scan now, the contrast, the extended length of stay, etc., and defer that to an outpatient setting.” So those are some examples.
Kevin Pho: Now, what were the responses whenever you talked to nurses about what life was like on the other side? Did it really help smooth the transition?
Ronald Hirsch: I think it did. I think they got a different perspective on things. Again, the nurse who’s working their eight- or 12-hour shift, you sometimes forget that the doctors that you’re contacting by phone are home sleeping. They’re not in another hospital on duty overnight. And remembering that, let’s be organized, so when you make that phone call, they’ll have a checklist in their mind: “OK, I need the old labs. I need the medication list, so that I can give the doctor everything they need when I make that phone call.”
Kevin Pho: Now let’s flip this to the other side. A lot of physicians train in academic medical centers, and then when they go to community hospitals, it’s a totally different environment. I know when I trained at Boston Medical Center in Boston and moved to Nashua, New Hampshire, which is a relatively smaller town 45 minutes north of Boston, it was a completely different world. So tell me the stories and advice you would give to physicians transitioning to a more community setting.
Ronald Hirsch: You know, I think it’s changed a little bit with hospitalists, because a lot of hospitals do have hospitalists on duty. But for the physician who’s still doing private practice or rounding on their own hospitalized patients, I think the most important thing is to remember you’re part of a team. The nurse, the dietitian, the housekeeper, the chaplain, all of those are playing a crucial role in your patient’s care.
Probably the most important thing is to remember that when you’re not in the hospital, what you document in your medical record can make the difference in how your patient is cared for. Our EMRs are communication tools. They’re not billing tools. Make sure you explain in your notes what you’re thinking about, what you’re worried about, and what you’re planning to do, so that everybody who comes in and encounters that patient understands it.
And again, the nurses have a job. They’re not allowed to make clinical decisions. So if they’re asking you for something, remember that they’re not allowed to tell you what the patient needs. They’re asking for your advice. They’re going to present the clinical picture. It’s not their fault that the patient spiked a fever at 2 a.m. We have to be nice.
Kevin Pho: Now tell us a success story where, in your role as a physician advisor, there was a potential conflict, say between a doctor and a nurse or a doctor and administration, and how did you move the needle and solve the problem? Can you tell us a story or case study that can really illustrate that?
Ronald Hirsch: So I can remember several times, and actually probably one of the most enjoyable things I did, where the family was confused about what’s happening with their loved one. It was a patient in the intensive care unit, and the nephrologist came in and said, “Well, he’s doing better. Your grandpa’s creatinine is down from 8.5 to 8.2.” And the pulmonologist said, “You know, it’s looking better. We’re down from 80 percent oxygen to 70 percent.” And the patient was still intubated, paralyzed in the ICU, unlikely to survive, because this patient had metastatic cancer.
What the nurses saw was the family getting messages of improvement, but yet nobody was putting that big picture together. So with me as a physician advisor, they were able to come to me and say, “Hey, can we set up a family meeting? And maybe you can attend as kind of the medical moderator to help them understand everything that’s going on with their loved one,” so that they’re not worrying about the creatinine level or the oxygen level, but really, what’s the prognosis, what’s the treatment plan, etc.
Kevin Pho: We’re talking to Ronald Hirsch. He’s an internal medicine physician. His KevinMD article is titled “Physician secrets that nurses need to know.” Ronald, you’re a regulatory expert. What’s something that’s not obvious about regulations that practicing physicians should know about?
Ronald Hirsch: Wow. Well, I spend a lot of my time with admission status in the hospital. It’s a constant frustration for physicians to have someone second-guess their judgment about hospitalizing patients. In general, insurance companies and Medicare are not questioning the need for the patient to be in the hospital. They’re questioning the admission status. And the other problem is that each payer may have a different set of rules. So Medicare has what’s called the two-midnight rule. A commercial insurer may use MCG or InterQual as their guideline for admission status.
Physicians need to understand that nobody likes to play this game, but it’s a game that we have to play. If we get the admission status wrong, the hospital gets paid nothing for the whole hospital stay. The patient got better, got great care from the physician, but it’s not paid for.
So again, understand that the utilization review staff is part of the team. They’re there to help. You know, if the hospital doesn’t succeed, it’s going to close one day. We’re going to have to lay off nurses, stop paying for housekeeping, whatever else it is. The advances in surgical services aren’t going to be there if the hospital doesn’t get paid.
Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?
Ronald Hirsch: I think for physicians, again, and I’ve stressed it here a lot, use the medical record as a tool to communicate with the rest of the care team. The new coding guidelines make that very easy: no more review of systems, no more social history if it’s not pertinent, or family history. Tell that story in your notes. Remember, at 2 a.m., someone may come along to take care of your patient, and if they can’t figure out what you were thinking about, what you saw when you examined the patient that day, they can’t provide that patient great care.
You’ll hear a lot of criticism of EMRs, and they’re obviously flawed. There are all kinds of problems. But you can always free-text your impression and your plans and tell that story. Let’s provide great care for patients.
Kevin Pho: Ronald, thank you so much for sharing your time and insight, and thanks again for being on the show. Thanks for being here.
Ronald Hirsch: Thank you, Kevin.
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