Where’s my doctor?

To understand this post you need to know what a hospitalist is. Basically, a hospitalist is a physician who practices in a hospital and hence their primary loyalty is to the hospital system.

When a patient is admitted to hospital, the hospitalists take over. The idealized image is that the patient’s regular physician will be part of the hospital care team but apparently that philosophy is honored more in the abstract than in reality.

It is better to understand typical relationships between your usual physician(s) and the hospitalists before you or a loved one ends up in a hospital system.

Here is a quote taken from Medterms

Hospitalist: A hospital-based general physician. Hospitalists assume the care of hospitalized patients in the place of patients’ primary care physician.

The term “hospitalist” was first introduced in 1996 by RM Wachter and L Goldman to describe physicians who devote much of their professional time and focus to the care of hospitalized patients.

Here are some passages taken from a piece called Three Degrees of Separation printed in the December Annals of Internal Medicine by Howard Beckman which I have found at the blog DB’s Medical Rants:

My experience with Ms. Sampson’s care has become the norm. After almost 2 decades of admitting to the same hospital, visiting patients there now feels like entering a foreign world. When I agreed to the hospitalist system, I believed that I would be a member of my patients’ hospital team. Primary care doctors would collaborate with hospitalists to assure that the art as well as the science of medicine would be maintained. However, that fantasy has yet to be fulfilled. I am notified by fax of a patient’s hospitalization. I am seldom informed of a patient’s arrival in the emergency department or consulted to discuss their impressions and integrate my knowledge of the patient’s ambulatory course into the decision-making process. Most of the time, I find out about patients in the emergency department because they or their families call me. Patients erroneously assume that I have been part of the admission conversations.

My belief that hospitalist care would result in “abandoning my patients” has largely been validated. As a new system replaced the old, we have lost continuity of care and the core element of effective cross-coverage: skilled explicit transitions of responsibility from one clinician to another. What the Sampsons should have heard was, “I’ve talked with Dr. Beckman. We agree that the CT decision can be delayed until your respiratory symptoms improve.”

Patients and their families are asked to make important decisions for which they often have little knowledge or preparation. Their primary care doctor is often the bridge and the translator. When I support my hospitalized patients by visiting them, their relief when I arrive and their smiles, hugs, tears, and questions confirm the roles that trust and continuity play in caring for those moving from the comfort and predictability of home to the loss of control in the emergency department or hospital. Quality of care includes patient-centeredness. If we ask hospitalized patients and their families what they want, I doubt that they would choose the current model.

The new system has evolved on the basis of incentives. What incentives do hospitalists have to understand Ms. Sampson’s perspective? Because of rotational coverage systems and infrequency of admissions, it is unlikely that the admitting hospitalist will care for her again. What incentives do primary care physicians have? Systems do not reimburse for sending records, talking by telephone with the hospitalist or family, or visiting the patient. How much value does past knowledge or continuity of care play in diagnostic decisions? How valuable is the family or patient’s perspective or their agreement with the care plan?

I am not sentimental and don’t wish to return to the “old days.” I believe in identifying and promoting best practices and encouraging the efficient use of available resources. A system that uses hospitalists can adhere to guidelines, provide organized team-based care that reduces medical errors, and improve outcomes. However, if our goal is to continually improve care, hospitalists, primary care physicians, and administrators have to partner more effectively. Are patients receiving the integrated care they need? How should primary care physicians be involved in decision making and care transitions? Are hospitalists satisfied with the care delivered, and if not, how could the process change? Finally, do the incentives in place encourage improvement?

When I entered Ms. Sampson’s hospital room for her latest admission, she said, “Thank God you got here, I can’t figure out what is going on.”

You can find my source for this extended quote here.

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