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Friday, December 21, 2007

Everyone agrees -hospitalists are here to stay

With the publication of a recent observational study published in the NEJM which seems to indicate that hospitalists save a little money ( read the latest by the Happy Hospitalist and you just might conclude it is more than a little money- see below for link) and do not seem to have proven harm to the patients,several prominent medical bloggers ( Dr. Wes, The Happy Hospitalist, and Dr. Wachter) all seem to agree that we have a win-win situation. It is win-win at least as far as the doctors now known as hospitalists ( and sometimes noturnists) and the hospitals are concerned and sometimes for the internists and family docs who now no longer manage their patient's care when they are hospitalized. There is always at least one sour note.

In this posting, Dr. Rob expresses no little dissatisfaction that he can't find out in anything like a timely fashion what the heck the hospitalists et al did with his patient in the hospital.Further, I am becoming more and more of the opinion that patients tend to be in the win column as well except when they go back to their primary care doc to find out what happened to them in the hospital. I hasten to point out that this is not be case with every hospitalist-patient-PCP encounter set but obviously sometimes it does happen.

Dr. Wes points out that when we go to the hospital we now have the doctor rather than our doctor. That is ,the primary care doctor who attends the patient when he is not in the hospital hands off the patients to the hospitalist who in the course of the patient's stay in the hospital may himself hand off the patient a number of times. The recurrent discontinuity of care at least so far has not been proven to cost anything in terms of cost to the hospital or morbidity of mortality of the patients. One might argue that the loss of one aspect doctor-patient relationship could be lost but no dollar value is typically assigned to that. And as Dr. Happy Hospitalist points out , there was no shortage of hand offs on weekends between docs in the same group anyway, so what's different now.

As Dr. Wes states and as the Happy Hospitalist has explained clearly the current economics of medical care is such that the dichotomy of "officist" and hospitalist makes sense and the former practice of an internist playing both roles perhaps was only possible in a long gone economic environment.

I chafed against the concept of a hospitalist and mourned the apparent terminal condition of the type of internist that I enjoyed being for a number of years but now if I were just entering into a medical life as a general internist I believe I would have to take the road of either the hospitalist or the physician with a retainer practice. As pointed out by DB the retainer doc can have the time to do a good job in the office .We all know that the time pressured doc is a prefect recipe for missed diagnoses, poor judgment calls, pride and sometimes ethical damage to the physician and loss of respect of the patient. The retainer doctor has the time and the hospitalist practice -as least of the type that Dr Happy Hospitalist lives- does also.I think as far as general internists are concerned. Mr. Dylan's advice might be heeded.

..you better start swimming or you'll sink like a stone.For the times they are a changing


The Happy Hospitalist said...

Dr Rob brought up very great points. One of the differences between a good hospitalist program and a great hospitalist program is communication.

Communication with specialists
Communication with the referring primary care doc.
Communication with the pateint.

Our hospital has a priority code for transcribing our discharge summary. It is transcribed and faxed within 24 hours.

And we AlWAYS call the PCP on the day of discharge to discuss the hospital stay.

While you can't please everyone all the time, you can certainly make it easier to get to that point.

The systems and culture must be in place to make a hospitalist program WIN-WIN

Anonymous said...

the identity of the primary physician is frequently a mystery to the specialists. a big one. most of the calls i get are from the clerk, with no idea of the specifics of the request. so there are communication issues on both sides.

if you call the hospital trascription service and ask how many primary care docs have blocked sending of discharge summaries and transcriptions to their office you would be shocked. some primary care docs don't want to be called because it disrupts their day, unless something unexpected occurs. lastly, as a specialist, i feel that when this communication has been provided to the hospitalist, it is their job to concisely summarize these things for the primary doc unless there is a special issue requiring urgent attention that could not be reliably communicated by them. if the primary docs would like a call, just tell the patient to have the specialist call them directly or leave a note in the chart. i'm sure they would get sick of calls if the hospitalist called them, the nephrologist, the pulmonologist, the cardiologist, and the radiologist all suddenly started interrupting their daily routine with calls on all their patients. but i would be happy to call anyone. a lot of times it takes someone 5-10 min to get to the phone. that starts to add up over the course of the day.
the first hospitalists probably were very good at all these issues, having been experienced physicians who worked closely with their community before becoming hospitalists. now that we are just throwing bodies into these 'higher paid, lifestyle' internal medicine positions, these new practioners have to learn these things. my experience has been that many hospitalists did not grow up in the united states, so there may be some cultural issues to overcome as well (or not). frequently they are swamped from day one. they also are often new to the area and learning to practice medicine as well.

Anonymous said...

Our family has just had their first experience with a hospitalist. My parent went into the emergency room from a nursing home. She was very dehydrated, and the hospitalist indicated her condition was grave. She did bounce back, however the hospitalist felt that a decision needed to be made about a feeding tube. With my parent suffering from late stage Alzheimer's, this is not something she would have wanted. We decided against the feeding tube, and the hospitalist suggested hospice care. We concurred, and she is in an End of Life program at a different nursing home. She's been weakend by the ordeal, but she's hanging in there.

My concern is that the primary physician has never spoken with us. It is a huge emotional step to have a loved one enter into a hospice situation, and I really feel some reassurance from her primary physician would have been appreciated. After all, we CHOSE him to be her doctor, not the hospitalist.

This is especially disconcerting in that her primary doctor is also our family physician. It just seems that when one is truly ill enough to be hospitalized, the primary physician should use his or her connection with the patient, at the very least to reassure the patient.

I feel we made the right decision, but I sure would have appreciated some input from someone we knew and trusted.