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Becoming a PA


A reflection on hospital medicine

Burke, Antoinette

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doi: 10.1097/01.JAA.0000830200.39644.38
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The Cerner electronic health record (EHR) update had all the seasoned physicians in a tailspin. “Where are my order sets?” “Why can't I use my old template?” “I can't click out of this chart until I select an admission status.” “Why can't I copy/paste?” In quintessential hospital fashion, the computer had exerted itself as kingpin of the wards.

The cardiologist looked at me and asked, “Are you a Cerner superuser?” I said, “No, I'm just a regular Millennial. What do you need help with?” My reflexive Millennial nature was to be annoyed at this Boomer who could likely perform open-heart surgery but couldn't handle a software update. However, I gave him the benefit of the doubt and listened as he explained his frustration with the changes. Simply put, he mostly felt they were not benefiting the patients or physicians in any way—that they were only making it easier to code and bill, capturing more diagnoses (regardless of clinical validity), and making the hospital more money.

I have always been drawn to hospital medicine. There is something so satisfying about figuring out a problem, coordinating all the pieces of a puzzle, and making a patient feel safe and cared for while doing so. The reality is that this mindset is shockingly altruistic within the constraints of hospital medicine.

My first day on my inpatient medicine rotation, the NP charged with my orientation said, “This isn't where you are going to learn clinical medicine or practice all your fancy tests. This rotation is about note writing.” These small conversations with the cardiologist and the NP opened my eyes and mind to one key concept of inpatient medicine I had not considered before: that the hospital itself is the primary patient. Whether due to the demands of patient census, or of a system that constantly pushes to increase revenue, internal medicine notes start to read like outsourced labor parts for a car assembled in the United States or a celebrity with too much plastic surgery: engine, Japan consulted; transmission, Mexico consulted; breasts, Dr. Terry Dubrow consulted; nose, Dr. Paul Nassif consulted; acute kidney injury, nephrology consulted; acute decompensated heart failure, cardiology consulted.

I am choosing to reflect on this component of inpatient care, possibly the art of the practice rather than the science of it, because I think it is in this realm where burnout becomes apparent. How do we provide all the best care while practicing within the constraints of the bureaucracy? This rotation was important to me because it really opened my eyes to the characteristics that I don't want to become a part of my practice and thereby solidified qualities that I do think are important and want to keep working on. I don't want to spend time digging through a chart to find one instance where a patient was mildly hypokalemic (due to diuretics we prescribed) and code for that just to offer no intervention. I don't want to miscode something that will then become part of a patient's medical record. I don't want to copy/paste to line the pockets of CEOs who studied finance and don't give back to their employees.

I do want to spend time listening to and examining patients. I do want to be well-versed in all aspects of clinical care, including the monotony of medical billing and coding. I do want to remember that patients' lives continue after they are discharged, and that the medical bills will go with it. I do want to find a better way to bring us back to focusing on bedside care instead of money, and I am not alone in this sentiment. Although much lip service is given to patient-centered care, many physicians feel that the system is increasingly driven by money and metrics.1 I find it so ironic that so many of us are drawn to a field that positions itself as a hands-on career, and yet we spend much of our day on administrative tasks. A 2016 study showed that physicians from family medicine, internal medicine, cardiology, and orthopedics spent nearly 2 hours in the EHR and on other desk work for every 1 hour of direct patient care.2 I also find it ironic that most of us coming into our professional careers have grown up with technology and are accustomed to it, but we simply aren't interested in it if it takes away from meaningful work instead of adding to it. The EHR, initially lauded for its potential as a repository of patient information, has become a tyrannical, time-consuming billing tool; it must be reconfigured to work for clinicians rather than forcing clinicians to work for it.1

On my last day of rotation, I didn't know if I would have done anything differently. Of course, I have room for improvement, but I will never learn anything if I start out thinking I am doing everything perfectly. I am proud of the work I have done, the choices and mistakes I have made, the extra time I spent on site performing physical examinations, talking to patients, updating them on laboratory results or imaging, or to build rapport with them so they would feel comfortable opening up. I feel proud that I committed to learning clinical medicine and performing my “fancy tests,” even though I was always the last one out the door. I feel proud that I took time to care for other people and not to just care for myself and my time. I don't know what the solution is to get us back to spending our time in front of people instead of computers. Until then, I will still prioritize my clinical decision-making to align with best patient care. I may be just a regular Millennial, but there are millions of us ready to change the status quo.


1. Hartzband P, Groopman J. Physician burnout, interrupted. N Engl J Med. 2020;382(26):2485–2487.
2. Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med. 2016;165(11):753–760.
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