Thursday, January 26, 2012

How do we feel about hospitalists?

I had missed this original MedPage Today column by George Lundberg back in November and so was pleased to catch it as a re-run over at Kevin, MD.  George asks the question, "Are Hospitalists a Boon or a Bane, and for Whom?"

A hospitalist, you will recall, is an internist who is the surrogate for your primary care doctor when you have been admitted to the hospital.  Before the hospitalist movement started in the mid-1990s-- thanks in great measure to Lee Goldman and Bob Wachter at University of California San Francisco -- your PCP would be in charge of your care at the hospital. S/he would visit early in the morning before taking office appointments and then again in the evening to check in on you.  If important issues came up during the day, someone at the hospital would call the PCP to determine the course of action.

The idea of hospital medicine is that these trained doctors are there full-time to check up on you and intervene as necessary in your care.  Being on staff, they would know the in's and out's of the hospital, the flows with radiology, physical therapy, laboratories, and the like.  They could also explain things to you and members of your family when it was convenient for you, rather than outside of normal business hours.

George notes, however:

I hear many anecdotes of problems such as:

1. Handoffs of patients from the community physicians to the hospitalist and back being fraught with communication gaps and flaws with increasing likelihood of resulting medical errors.

2. Hospitalists having to do the "hospital's bidding," usurping physician autonomy and judgment to the corporate advantage of the hospital.

3. Hospitalists refusing (or being unable) to provide competent and comprehensive care to patients under their responsibility.

4. Hospitalists serving as little more than triage persons, routing every little symptom or finding to this or that specialist (headache to neurologist; tummy ache to general surgeon; heartburn to gastroenterologist; cough to pulmonologist; chest twinge to cardiologist; anxiety to psychiatrist; skin blemish to dermatologist).

I was really taken aback by this.  Maybe my sample is biased, but the experience I have leads me to have the highest regard for hospitalists and for their role in taking care of patients and families. Far from triage persons, they have the time to get to know patients and avoid the need for more costly specialty care. I have found them to be the leaders, too, in process improvement designed to reduce harm and ensure safety.  Here's an example from BIDMC, where hospitalist Melissa Mattison developed a  protocol for reducing the likelihood of falls among elder patients.  And here is hospitalist Julius Yang explaining the fundamentals of Lean process improvement. 

Indeed, primary care doctors can no longer carry out those tasks.  (The exception is concierge doctors who limit their panel of patients to just a few hundred people.)  PCPs are overwhelmed by the demands of their office practices.  Were they to try to visit their admitted patients, they would have little time for in-depth assessments.  Also, they would find themselves left behind on the latest clinical processes in the hospitals.  And they certainly would not be effective in implementing process improvement in the complex hospital environment if they could only be present for a few hours.

But let me pose the question to this audience.  The comments on George's initial article and on Kevin's reprint tended to be negative about hospitalists.  What has been your experience?  If it has been negative, please answer this:  How well do you think your PCP could have taken care of you in the absence of the hospitalists?  Do you think you would have had a better experience?


Anonymous said...

Hospitalists represent fully the tradeoff in the equation of continuity of care, and so, stand in the middle of either model.

Poor health education and support, and continuity and strength of prevention before a patient reaches the hospital doors (as most of the public experience) make a hospitalist the final savior to a system that is always inadequate, always a poor foil to the reality of life's assault.

Patients reach the hospital door, and now at least someone is there who at least can negotiate those byzantine complexities of interdisciplinary in-patient care. I've heard the same derision. But hospitalists are (and should strongly be) held accountable for the most updated infection control, reporting and coordination systems. For complex, multiple morbidity cases, this knowledge, and the skill to know how to anticipate and coordinate care in a fast-moving high tech setting is critical. Literally.

But hospitalists are there because medicine isolated primary care in the first place. Payment systems said 'high cost, high tech, you-are-almost-at-the-end' care is more valuable than 'we better get this blood pressure under control or you'll need medication' kind of care. Beat up the hospitalists, but the denigration rather than elevation of primary care in medicine at large and historically is the culprit.

If medicine valued my PCP as well as she deserves, she would be able to walk into any hospital and have a surgeon bow, and ask "What do you think?"

Whipping hospitalists completely misses the point. My prediction? As we put nurses out in the community, and say 'oh, don't worry. We'll just hire more nurses and that will solve the ACO challenge (i.e. prevention).' In only a few years time, we will say 'oh, those nurses. They just don't know how to do prevention.' So goes the blame game.

Hospitalists are there because we never solved the first problem. That is, that we never put PCPs at the top of the food chain - with the most respect and the most accountability. It is a bad fix that hurts everyone because it isolates the most intimate caregivers from the most high tech solutions - and the most high tech practitioners from the most developed high-touch skills demanded where people really encounter health. Oh, yes. Next we'll blame the patient for not knowing who their doctor is.

Senior Home Care Maryland said...

I think it depends on the will of the doctor that he takes interest to improve the environment of the hospital. On the other hand, it also depends on the hospital authorities that how they monitor their staff.

Anonymous said...

Paul, you and I had a recent comment exchange on this on a previous post, where my experiences with my elderly relatives did not conform to yours. I think we are not taking into account the consequence of dropping this new specialty of hospital medicine into a pre-existing bad system. Why should we expect them to swim in these dark waters any better than anyone else? To the extent that maybe, and I say maybe, they improve on how a PCP would have done, it's just another workaround.
I believe your good experience was probably due to the overall better processes and culture in your hospital.


Anonymous said...

1.Handoffs of patients from the community physicians to the hospitalist and back being fraught with communication gaps and flaws with increasing likelihood of resulting medical errors.

So you think if primary care docs were to see their pts in hospital, this issue would improve? Or it that even an option ( given the time pressure they have even for their clinic patients)?

2. Hospitalists having to do the "hospital's bidding," usurping physician autonomy and judgment to the corporate advantage of the hospital.

On this, how would a primary care doc do it differently if he/she were to replace a hospitalist?

3. Hospitalists refusing (or being unable) to provide competent and comprehensive care to patients under their responsibility.

Now thats a joke. Both internal medicine primary care doc and hospitalist have SAME training. And PCP spending 20 min or less with a patient, one can only guess how wonderful the pt care quality would be.

4. Hospitalists serving as little more than triage persons, routing every little symptom or finding to this or that specialist (headache to neurologist; tummy ache to general surgeon; heartburn to gastroenterologist; cough to pulmonologist; chest twinge to cardiologist; anxiety to psychiatrist; skin blemish to dermatologist).

Yes, as if primary care docs dont sent their pts with -headache to neurologist; tummy ache to general surgeon; heartburn to gastroenterologist; cough to pulmonologist; chest twinge to cardiologist; anxiety to psychiatrist; skin blemish to dermatologist.

Bottom line- Darwin was damn right-"In the struggle for survival, the fittest win out at the expense of their rivals because they succeed in adapting themselves best to their environment."

Diana said...

In response to your questions of hospitalists vs PCP in taking care of a patient: My mother had a hospitalist in place of her PCP. The hospitalist and PCP did not communicate about a serious drug allergy which was given against even the hospital's pharmacy's policies, causing her to go into shock, requiring ICU care for >1 month. This destroyed any possibility of recovery as the trilogy of infections (MRSA, sepsis, c.diff) got her, resulting in death. I'd say this was 50% personality & culture, and 50% training. The hospitalists' days of getting to know the patient in an acute care setting could not possibly be equal to several office visits with candid conversations while the patient is lucid and not scared to death about just being in the hospital with a serious illness.

Thomas Pane said...

Hospitalists are a net positive. Yes there will be some handoff and other issues, and some institutions with conflict-of-interest problems. But the in-house patients of today are sicker than in past eras. So the hospitalist adds more value than having floor nurses check in with a PCP's office during the day.

On the other hand, hospital work has become more cumbersome and the economics of being in the office and hospital on the same day often doesn't fit.

The hospitalist specialty may be the first that has developed from workflow issues rather than physiologic advancement. Similar factors are now developing the surgical hospitalist and obstetric hospitalist.

Anonymous said...

As is so often the case, it is both/and. The vision for hospitalism is tremendous, as Paul describes. As each year passes, the hospital and office become further apart in how processes get done. It is unrealistic to expect one doctor to be able to navigate two ships that are so diverse.

Because of this, hospitalism will grow. At our hospital, we have nearly 100 doctors on 9 teams in 8 specialties.

That said, we have so far not lived up to the vision of our young specialty. We have a way to go in improving communication and handoffs in order to keep patients safe. While our leaders cite "palliative care" as a core competency, too many of us defer important goals-of-care conversations to someone else along the care continuum.

Nonetheless, hospitalists are right in the center of the health care transition in America, managing patients in the most expensive (and probably most wasteful) sector. We are poised to lead hospitals to being centers of efficiency, appropriateness, safety, and compassion.

All in all, I think hospitalists are better for patients, better for hospitals, and better for the country.

Joanne Roberts, Everett WA

Unknown said...

I was hospitalized for 6 days with a blocked intestine. While surgeons reviewed that situation daily, a hospitalist decided that my thyroid medication needed to be lowered by half and it needed to be done right away. She cut the prescription dose I was being given intravenously while in the hospital without consulting my PCP and ignored that I told here that it took my doctor months to raise it to that level. It seems her desire to do some "doctoring" and her inflated sense of importance outweighed a more measured approach to what was not her problem to solve. Thyroid levels were tested by my PCP after my release and I returned to the dose prescribed to me when I entered the hospital.

Anonymous said...

Quite simply... After a Hospitalist messed up my recovery from surgery by mis-calculating my pain medication, resulting in my receiving one-half the originally ordered dosage, ordering a salt-free diet which was so inedible I actually went 4 days without any food at all except a slice of bread at each meal (for no good reason anyone could see), then failing to see that an order for SCDs and ice was being carried out on the post-surgical floor (neither ever happened) and another Hospitalist at the same hospital just kept my landlady in the hospital an extra night even though he has not seen her since two days ago in the ER (I know, because I have been there every single hour of every day since she left surgery). I have lost ALL confidence in Hospitalists in general and in this particular hospital as well... He has also failed to order her metoprolol and her thyroid medication even though I've been mentioning it to the Nurses for days.
Nope. I want my PCP in charge even if he cannot come to the hospital. I'd rather have my PCP in control by phone than any Hospitalist in physical proximity.

Anonymous said...

My local 'hospital' very recently adopted this hospitalist model. It has been my experience that it is terrible and the whole idea thrown on the scrap pile.

My mother, who has dementia and cannot move, was taken to the hospital for aspiration pneumonia. This year, she was in twice for the sickness. Between the first admission in spring and this one in August, Hospitalism was adopted. The ER doctors who knew her were nowhere to be seen. Instead a group of doctors unfamiliar with her treatment, put her on a breathing machine and knocked her out. When I got there, she was totally unresponsive and I was told she would die. I called in her family and had the doctors remove her from the breathing machine in the ICU. Yet twenty-four hours later she still was alive. She was then taken to a room and left there without any food or treatment. I had to request that the Hospitalist restart treatment and give her some nourishment. But she argued with me that I shouldn't get my hopes up. After she finally shut up long enough for me to get a word in edgewise, I explained to her the procedure her PCP gave to my mother. Reluctantly, she acquiesced.

My mother continued to improve using the treatment regime set up by her PCP, with whom the Hospitalist refused point-blank to consult as it "made no difference" and that she went "by the machines and charts". She has a know-it-all obnoxious attitude. I looked her up on the web, and found out she's exited hospitals and practices all over the lower Southern states. That physician is an example of all the ills that plague this silly notion of being expert in hospital technology. She's just a bureaucrat with an M.D. behind her name.

Anonymous said...

My right leg became swollen and red and was hot to the touch. I feared a blood clot. Went to a Methodist Hospital ER place and was admitted for "something". They called in a hospitalist who started IV's of antibiotics after a doppler did not detect a clot. She said I had cellulitis from "soemthing". There I layed for 4 days and had IV's every 12 hours around the clock. I asked her to please call in an infectious disease doctor as I would like to talk to one. She rebelled in anger. They list a whole bunch of diagnosis codes and I knew I was not a COPD patient but they sent in a respiratory therapist anyway who agreed with me that I did not have COPD. I wanted to see doctor's I knew but this did not happen. This hospitalist only came in to see you in the early hours of the AM. I wanted my husband there but 7:00AM he could not be there that early. Lived 90 minute drive away. No other contact with this hospitalist was permissable, we were told. I wanted out and told her to discharge me as I needed to see an infectious disease doctor for answers. I did see one 5 days later. I did not need IV' antibiotics for 4 days as I did not have an infection, the infectious doctor said and appalled that she was not called in on my case. She referred me to a Vascular surgeon. She said that is who should of been called in on my case, too. I have learned NOT to return to this hospital as it is not patient friendly. Seems Hospitalists call the shots....even when they are wrong. Don't piss them off. Try not to get admitted. Call for social services and see if you can be treated at home for "something".

Paul Levy said...

So sorry about your experience. I have generally found quite the opposite to be the case, but there is a lot a variation in the world.

Jill Van Cleve said...

Many of the "benefits" of using hospitalists refer to easing a PCP's load.
But now,at 75, nearly all my doctors are specialists and, if/when I am hospitalized, it upsets me greatly to have some total stranger, not eg a pulmonologist just blindly in his ego-driven ignorance, start refusing to order meds, originally prescribed by an allergy/asthma specialist, that for 20+ years have kept me alive.
Or the guy who suggested an antibiotic of which had never previously heard, go on to point out that yes, it would cause a "renal void" but oh well....He thought, I'm sure, I would not know what a "renal void" was....
--The hospitalist who came rushing to my bedside waving a printout, insisting it strongly indicated lung cancer.... My specialist of many years said, "It could just be inflammation."
It was "just inflammation" but I had to go through the shock, worry--as did my family--caused by an inexperienced "hospitalist" wving a printout and blabbering about cancer....

Maybe hospitalists can validly replace PCPs. They cannot, and should not be allowed to presume differently, replace specialists.

Jill Van Cleve

Anonymous said...

I've been a patient and I'm also an MSN. I think the hospitalist program is a horrid idea! Who wants some doctor taking care of them that the patient does not even know? What ever happened to doctor patient relationship. How can you be sure they consult with your PCP unless you are your own advocate? There is the science of medicine, but also the art. Sad decline in medicine.

Anonymous said...

Book Mont,
The IV to PO conversion for levothyroxine is 1: 2. Not something that a typical PCP would know, as they don't use IV levothyroxine. And, it appears, something that your surgeons missed. Your hospitalist did the right thing!

Anonymous said...

Absolutely agree. Hospitalists benefit hospitals, not patients. They know NOTHING about the patients they are treating, unlike a PCP who may have ben treating a hospitalized patient for years. The hospitalist gathers fragmentary history at best, no history at worst. This so-called 'innovation' is another example of how the US healthcare system changes to benefit the system itself and not the patient.

Anonymous said...

Having been a patient and daughter of patient. I think this trend in medicine is bad. Without a knowledge of the history all they do is repeat test unnecessary to cya. So you have an elderly patient getting a stress test even though they had on a month before. What happen to communication in medicine.

Unknown said...

I completely disagree. The hospitalists I have a had to deal with are not interested in doing what's right by the patient, but by the hospital. They do not take the time to get to know you. You're lucky if they read your chart before they enter your room. You are a hostage to their opinions and personal beliefs. God help you if you have a chronic problem. If they see you too often, they may admit you but they'll refuse to treat you. They are the worst thing to happen to medicine

Anonymous said...

I just got out of the hospital, not once
Was my pcp contacted or allowed to
Contact me. Medication was wrong and I don't even think my chart was looked at. I was lucky if I saw the same
Dr twice the 8 days I was in there. Pcp
Is through same hospital. My pcp tells
Me that the hospitalist over rules his decision on how I take my meds even
If I only see them once. This is screwed!
My sugar stayed up wasn't giving me
Full amount. Given iv antibiotics while
In there I had a allergic reaction to which was in my chart(same system)
Spent more time in.Hospitalist are
Dangerous. Give me my own little black
Bag and I will treat myself. I've been out of the hospital system a long time.
They sound like a title of a horror movie
Title. "The Hospitaist are coming" a
Life style choice and not the care of a
Patient. No Thanks...see less pts in the
Clinic, don't dump your patient at the

Anonymous said...

I agree 1000% !!!! Hospitalists usurp the PCP's role. I want MY dr taking care of me when I need him the most. He knows me well (after treating me for 30 years). I don't want some dr I dont know and dont have a relationship with directing my cate.

Anonymous said...

I hate hospitalists. My husband almost lost his life because a hospitalist said he should go to rehab for several weeks to become more lucid (screaming pain was being treated with Ativan)before surgery . I told her the only person who would make any decisions about my husband was the Urology Surgeon. The surgeon operated within a few days. My husband’s kidney was the size of a football and weighed ten lbs. high pressure. Tumor was advanced from the scan the month before and had lymphovacular invasion. He would not have survived until Christmas if I hadn’t fought this woman.