Monkey medicine

Some days the hospital can feel like a medical oasis, a serene temple of healing, and an administratively well-oiled environment, designed for providing safe, high-quality, evidence-based, patient-centric, high-value care.

Some days, but not all of them. On those other days, the imperfect, “do your best in a complex world while you pull out the rest of your hair” days, you may feel like you've entered a zoo and your ward has become the primate house. You wonder how you got involved in all this monkey business.

ICD-10 has 10 separate codes for chicken-related disease but few codes for monkeys other than B04, monkeypox. There is nothing for initial contact with Japanese macaques, a bite from a black howler, or a subsequent encounter with olive baboons. To compensate for this lack of guidance from ICD-10, here are the terms you will need to be a successful hominid hospitalist.

Nie mój cyrk, nie moje małpy (not my circus, not my monkeys). This is a Polish phrase. In some ways it is similar to “I don't have a dog in that race” (see August 2017 Newman's Notions). While not having a dog in a race implies a lack of interest in an outcome, however, “not my circus, not my monkeys” has a somewhat more malignant feel. You know how to get something done—some simple solution, shortcut, or workaround—but you are disinclined to get involved. You watch while others do it the hard way. If patient safety were at stake, it would be another matter, but if your colleagues want to do things the hard way, it's their problem, not yours. You are not responsible for solving everyone's problems. Maybe that's why you're not in a leadership position.

See no evil, hear no evil, speak no evil. Imagine Drs. Mizaru, Kikazaru, and Iwazaru striding down the hallways together, making safety rounds. A previous inspection noted cluttered hallways, patients have complained about the noise, and the staff gets little communication from senior leadership. Dr. Mizaru sees nothing wrong, Dr. Kikazaru hears no loud noises, and Dr. Iwazaru has nothing to say about the conditions. In fact, Mizaru, Kikazaru, and Iwazaru are the names of three well-known monkeys on the 17th-century Toshogu Shrine in Nikko, Japan. In the Western interpretation of this aphorism, the monkeys are blind to the faults of the world, deaf to anything that seems upsetting, and mute when it comes to speaking their minds. But in the Buddhist tradition, it's more about not contemplating or perpetuating the evils of the world as opposed to ignoring them. Either way, the monkeys' lessons hold universal appeal, as evidenced by their presence everywhere from among Mahatma Gandhi's few possessions to the cover of MAD magazine.

Monkey on your back. Your quarterly bonus is tied to your patient satisfaction scores. You find yourself being nicer and taking time with your patients, but you realize you just cannot put HCAHPS and your rank on them out of your mind. You try, but you are drawn like a moth to a flame. You wait expectantly for the monthly rankings. You've got to score the highest in your division; you're a ratings addict. This means you have the patient satisfaction monkey on your back (unless of course you were just at a zoo where there have been repeated simian escapes, in which case you might really have a monkey on your back).

Monkey see, monkey do. This concept was popularized in the great historic literary work “Caps for Sale.” Monkeys have often been portrayed imitating human behaviors. Think back to the good/bad days of internship, before work-hour restrictions, mentoring, simulation, or even senior physicians available to teach. You watch your resident do a lumbar puncture. You watch the precious hard-won drops of fluid drip into the test tubes. Then meningitis is suspected in the next patient admitted. Your resident sends you to do it, while he goes to the call room. You are supposed to call if you need help, but you had really better need it if you do. You are not sure exactly what to do and why, but you'll give it a shot. This is also known in some hominid circles as “see one, do one, teach one.”

More fun than a barrel of monkeys. A barrel of monkeys is not fun. Perhaps the children's game, originally released under the name “Chimp to Chimp,” was moderately amusing, but the initial intent of the phrase is to describe a situation of havoc—monkeys gone wild. Think of a long day at work, with patients leaving AMA, relentless pages from housestaff, endless contentious meetings, and a monkey wrench thrown into every gear. When your loved one enquires as to the quality of your shift, the only appropriate answer is “more fun than a barrel of monkeys.”

But even when your admissions seem to come from primates, not primary care providers, and the cardiologists are acting like capuchins, the radiologists like rhesus monkeys, and the surgeons like simians, you can handle it. Put on your favorite Monkees song, jump on the bed in your call room, and eat a banana. Then get to work: no more monkeying around.