Physicians News Health news for doctors and patients.
Larry C. Kerpelman, Ph.D.
As a result of a freak fall while jogging, my wife, Joanie, sustained a subdural hematoma. It took three emergency room visits, two hospitalizations, one neurosurgery, and several months of rehabilitation before she regained her lost capacities. During her first hospitalization, we became acquainted with the hospitalist’s role which, while not new in the United States, was new to us. In the book I wrote about our experience with her injury, treatment, rehabilitation, and recovery, I included a commentary on the hospitalist phenomenon as we experienced it at one Massachusetts hospital. That commentary, below, is excerpted from Pieces Missing: A Family’s Journey of Recovery from Traumatic Brain Injury, Two Harbors Press, 2011.
With the rise of the hospitalist phenomenon, primary care physicians often now assume the role of passive receivers of information about the hospitalized patients for whom they normally have primary concern. Joanie had at least three different hospitalists caring for her during her first hospital stay of four days. Her primary care physician did not see her during that time, nor during her second hospitalization, either (she changed her primary care physician shortly after her second hospitalization, partly as a result of this).
A 1998 article in Physicians News Digest(1) states: “About 2000 physicians nationwide call themselves hospitalists. Specializing in the management of hospitalized patients, the hospital becomes their office. A hospitalist takes over for a primary care physician when it comes time to admit a patient. For your average primary care physician, this means fewer, or no, visits to the hospital at the end of their office hours for rounds. Usually working on flexible, yet intense shifts of eight to twelve hours, the hospitalist turns his or her pager off when the shift is over.”
In just eight short years after that article was published, the number of hospitalists practicing in the U.S. was estimated to have grown to 12,000, with the expectation that it will eventually grow to 30,000 (2). [The Society of Hospital Medicine estimates that the latter number has already been reached (3).]
Since a key role of the primary care physician is to manage health care for the whole patient, turning that care over to hospitalists while the patient is in the hospital (even if the hospitalists keep the primary care physician apprised) weakens that key component of caring for the whole patient. Moreover, a hospitalist does not have the same sense of connection with a patient that the patient’s primary care physician has. Plus, since different hospitalists often see the patient during a hospital stay, there is a greater chance that communication about each case is, perforce, going to be less clear than if only one person, the primary care physician, is handling the case.
Those in favor of the hospitalist movement counter that the hospitalist, being based in the hospital, is more available to both the patient and the nurses who provide care for the patient than a primary care physician, whose office is often not in or near the hospital, would be. Should untoward developments in a patient occur, the hospitalists are there to act. In addition, because they work defined shifts, hospitalists tend to be fresher and more alert than primary care physicians, who may see their hospitalized patients at the middle or end of a busy day, would be. Those sympathetic to the hospitalist movement also point out that hospitalists’ treatment and activities are monitored more closely by the hospitals in which they work than are those of primary care physicians providing care to their hospitalized patients.
All things considered, though, it seems to me that the major benefit of having a hospitalist care for a hospitalized patient accrues mainly to the primary care physician, who no longer has to suffer the inconvenience and wear and tear of visiting the hospital to see his or her patients, nor suffer the inadequate reimbursement that insurance companies provide for such visits. It’s the patient who gets the short end of the stick in terms of continuity of care, in my opinion. Although she is seen by hospitalists while in the hospital, she is not necessarily seen by the same one during the course of her stay, potentially leading to communication disconnections among providers and disruptions in continuity of care. Even if the patient is seen by the same hospitalist throughout her hospitalization, she does not receive the benefit of being seen by a physician—namely, her primary care physician—who has an in-depth understanding of her, her prior history, and her health concerns.
The point that some raise, that hospitalists’ treatment and activities are monitored more closely than are those of primary care physicians seeing their hospitalized patients, is hardly relevant. It implies that primary care physicians cannot be monitored as closely, but what is to say that they cannot? They may not be used to being monitored so closely, but that does not mean that they cannot be. Changes in hospital practice happen all the time (albeit slowly).
The medical community itself is not unaware of these issues, as they are a matter of vigorous discussion in the medical literature. An acquaintance of mine, an internal medicine physician who very much favors the hospitalist system, recognizes that most patients do not agree with him. “Patients hate it,” he plainly admits.
Although the whole hospitalist issue is still a work in progress in the medical community as it tries to adapt to this change and perfect its workings, I think that the medical community is inclined to believe that the tradeoffs are worth it to them. From the health care consumer’s point of view, however, the tradeoffs are not. Perhaps the vigorous discussion in the literature will come to encompass an examination of the shortcomings I have pointed out here and result in the provision of hospital care that is more satisfying and continuous.
============================================================
References
- Christopher P. Noel, “The Emerging Role of the Hospitalist.” Physicians News Digest (February 1998): p. 298.
- Niraj Sehgal and Robert M. Wachter, “The Expanding Role of Hospitalists in the United States.” Medicine Weekly 136 (2006): pp. 591-596.
- http://www.hospitalmedicine.org/Content/NavigationMenu/AboutSHM/GeneralInformation/General_Information.htm [accessed June 22, 2011].
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Larry C. Kerpelman, Ph.D. is an award-winning health care writer and editor who has published two academic books and written numerous articles for publications. His book, Pieces Missing: A Family’s Journey of Recovery from Traumatic Brain Injury (Two Harbors Press, 2011) is available from www.LCKerpelman.com, www.Amazon.com, or your local bookseller. He can be contacted at lkerpelman@gmail.com.
I experienced the hospitalist movement firsthand. There is absolutely no continuity of care. They don’t even state their position when then introduce themselves. I was placed on meds that I wasn’t informed of and only knew when the nurse stated them to me when I took them.
Some were meds that my “outside the hospital” doctors didn’t want me on. I was given the wrong dose of Coumadin despite constantly telling the medical staff the right dose and as you would have it my INR, which the hospitalist forgot to order and was put in the system by a nurse who didn’t want to bother the hospitalist came back subtherapeutic and I had to stay in the hospital one more day on heparin until I became therapeutic. Thank God for nurses. I believe they are providing the continuity of care that the protagonists of hospitalist like to credit them with.
I couldn’t think of a worse system of primary hospital care in which there is no physician to physician communication. Why doesn’t the medical community which disagrees with this system not ban together to make it more evident to patients that their family doctors won’t see them in the hospital because they get paid more in the office? What would be the FPs answer to “Why don’t you see me when I am in the hospital? Would they ever have the guts to say because I don’t get paid enough to do it. I know primary care docs can’t work twenty four hours a day, but there has to be a better answer then this chaotic system.
My mother died from intestinal eschemia which while difficult to diagnose is very treatable given a prompt diagnosis. Our hospitalist missed signs (history of afib, no presrciption for anti-clotting meds (coumadin)) and when we requested to contact her primary care physician we were told we didn’t need to call him; hospitalist said that HE was our doctor. As our hospital stay progressed, my mom’s symptoms were becoming more alarming and with very little doc intervention (we had at one point gone without seeing a doc for 20 hrs straight despite repeatedly asking to see one). When finally confronted, hospitalist asked if we wanted a new doctor. Ultimately when her conditon was diagnosed by specialists which we literally had to beg to see, it was too late. Diagnosis was 1.5 days after being admitted and in surgery it was discovered that nearly all her bowel was dead by then.
There may be some good hospitalists out there, but this lack of compassion, competency and patient knowledge is a systemic failure. I hope the supposed savings and benefits for the hospitals, insurance and primary care physicians are worth this screw job for the patients.
I am a hospitalist and I don’t like the way medicine is practiced. The big looser is the pt and the big winners are the hospitals and insurance companies….certainly not the taxpayers. There are certainly benefits to having a doc in the hospital and latest literature does show beneficial outcomes. It is not as bad as Dr. Frisher makes, it but certainly, even if I spent over 2 hours on a pt, which I don’t, it does not equal to the relationship between the pt and his pcp which could be over many years. We do review labs, records, talk to pts and other specialists. It is funny that a surgeon would complain about communication…the worst communication in medical care stem from surgeon. They do not return calls, do not write notes. If they do, they are not legible. If they are legible, often say very little to be of any benefit. However, it is diff. a problem. We write discharge summaries that we like to send to the pcp/consultants if the pt can recal who they were, but, common, how much can I say in the dc summary of a pt who has been in the hospital for over a month? As much as I hate it, it is the reality of today’s medicine…it is about money stupid, not pt care.
Most pts that I encounter are indifferent. They complain about their pcps, non compliant with meds etc. So, the sacred relationship that existed between a doctor and his/her pts, which drew me to medicine, unfortunately, is a thing of the past. Pt was treatment, usually for free, and a doctor is providing it while insurance and hospital executive get rich off “transaction”…never mind drug and medical device companies.
In conclusion, suck it up, if you are doctor or the pt and either go with the flow or make enough fuss to bring some changes.
As a RN for 21 years working in a hospital based system in Orlando, Florida, I have taken care of many patients who complain about their private MD’s not managing their care while hospitalized. Common questions posed to me at the bedside are: Why can’t I see MY doctor? Did he agree to this? Does the hospital get more money which my insurance pays for? Shouldn’t my doctor advertise or inform his patients that he uses Hospitalists?
This new concept is pushing out the private MD who for years took an oath and commitment to take care of HIS patients. Multiple physicians for one case where one’s Private MD can keep healthcare costs down but that would not benefit the financial gain that Hospitalists provide for hospitals.
In the long run, the private MD is being pushed out and the patient suffers the loss of establishing a truly confidential relationship with the doctor they thought would monitor their health.
Experiencing this type of care does frustrate the patient; lends to extended length of stay, repetitive history review,
unnecessary tests that could be done as a outpatient. Personally, I experienced this type of hospitalization and hope I never have to again. The AMA and ANA should support bringing the private MD back into the patients care when hospitalized. Insurance companies would benefit and more importantly the patient.
This is my view on use of “Hospitalists”.
I have been a physician since 1971. I have seen wonderful advances in medicine in those years but the hospitalist idea is the most terrible movement that I have ever seen. A patient that has many complicated medical problems is admitted to the hospital, a physician that is intimately aware of the patient ( family doctor ) has absolutely no involvement in the hospital care, a hospitalist drops by for a brief visit ( certainly not enough time to review a complicated patient) and is then gone, only to be replaced by a new hospitalist the next day (if you are lucky it is a doctor but it may be a NP). No continuity of care, no knowledge of what the last doctor was thinking. An electronic record of course which is a templated response and does not supply the true mental thoughts of the physician (although it does provide enough to verify the hospital charges that CMS is looking for). Then imagine that this doctor will have to see 30 complicated patients each shift, all new to him/her. A nightmare. As a surgeon I have to know my patient before and after surgery. I do not want to treat their diabetes or high blood pressure. I depend on internists, family doctors, whatever to manage the non-surgical issues. I have to “fight” to get a hospitalist to manage the medical issue of my surgical patients and the doctor that originally referred the patient to me no longer goes to the hospital. No computer system can ever make this better. The 12 hour punch a timecard doctor is NOT of any value to me. I consult with FP residents now because their staff doctor rounds on EVERY patient with them and therefore they have continuity. I dread the thought of ever having to be a patient. This is not good medicine.