Mixed Feelings About Hospitalists

Hospitalists are relatively new to medical care.  They are physicians who specializes in the care of hospitalized patients.  In other words, these doctors don’t treat patients in their offices, they take care of the patients admitted to the hospital so your primary care physician (PCP) doesn’t have to check in on you.  As this trend continues to grow and hospitalists become more common I have mixed feelings about the specialty.

Background:

The idea of a hospitalist began in 1996 following many reforms in how hospitals were run and providers were paid (I will leave out the minute details).

Hospitalists specialize in hospital care and are around the ward throughout the day.  PCP’s and hospitalists collaborate at admission and discharge, and the PCP follows up with the patient from there on out. The hospitalist is a specialist in hospital care

I was very confused when I met my first hospitalist about a year ago.  I grew up a doctor’s and pharmacist’s daughter.  I spent a lot of time hanging around hospitals – especially on weekends when my father was on call and we went to check in on his patients.  (Of course I stayed at the nurses station or in the lounge mostly).  I was used to the idea that if you were in the hospital, your primary care physician that you saw outside the hospital would come to check in on you in the morning and at night.  He knew your medical history and could safely see you through the hospital ordeal and back into outpatient care once released.  Thus, I couldn’t quite grasp the idea that someone else would be taking over patient care when hospitalized and then handing them back off to their PCP after.

I’ve thought a lot about this specialty since, especially with the emergence of specialty hospitalists (hospitalists that may specialize in neurology, ob-gyn, or other specialties) and continue to have mixed feelings.

The Good:

As I said above, hospitalists specialize in hospital care.  This means they are more familiar with the operations of the specific hospital you’re in.  They know how to work with the staff and nurses to coordinate your care efficiently during your stay there.  And they are around all day, whereas your PCP will be in the office all day and may only come in the morning and night to check on you – coming over only in an emergency.

Hospitalists also take over when you’re out of town, far away from from your PCP.  And for the uninsured or those who just never really selected a PCP or seen their PCP, the hospitalist can step in without a random physician group being called in to take care of the patient.

And again, hospitalists coordinate with your PCP to communicate about your care at admission and discharge.  This is made even easier with the advent of electronic health records (EHRs) (see my post on EHRs).

Hospitalists decrease lengths of hospital stays and cut hospital costs without a decrease in quality of care.  In fact, some studies have shown that care by hospitalists means fewer readmissions and lower mortality rates.  And having hospitalists as teachers in academic center hospitals have improved resident and medical student education.

The Bad:

Even with all the above, I still have some misgivings about this model of care.  I am concerned with being unfamiliar with a care provider, the discontinuity of care, the lack of responsibility for patients, and how it fits in with recent changes in medical care.

Honestly being unfamiliar with a care provider is my biggest concern.  I don’t like the idea that I have to tell my personal history to someone I’ve never met before and haven’t chosen to take care of me.  Patients don’t develop relationships with hospitalists in their (hopefully) short stays in hospitals.  While in a hospital, patients are at their sickest, they are vulnerable and exposed and without control of a lot and all the sudden a doctor comes in that doesn’t know them.  Sure, you divulge a lot on your first visit with any PCP, but then you develop a relationship and disclose more about yourself at each visit.  I can imagine that not everyone wants to share every detail with a person they just met – details that could be important like drug use or mental health issues.

In the absence of familiarity, continuity of care is something crucial to medical care and with greater emphasis on it through patient centered medical homes and electronic health records becoming more and more standard (why it’s taking so long, I have no idea).  Still, doctors aren’t great at it.  I’ve not yet heard of a doctor that gets and looks over a patient’s records thoroughly before talking to them – they have no idea of that patient’s medical history even if it’s available electronically.  I don’t really think they talk to each other…ever.  This is troubling to me.  Your PCP knows your medical history – your allergies, your home life, your stresses, your cultural preferences, your diseases and family history.   When you’re in the hospital you want someone who knows all of these things – especially when you are most vulnerable.  While the hospitalist can get quite a lot of this information, likely he or she will miss out on a lot.  Perhaps you don’t think things like stress and home life are all that relevant to your hospital care, but often those issues contribute to your health and even your likelihood to follow a treatment regimen.   Not having this continuity of care can disrupt your treatment.  While the studies are showing that outcomes are about the same, I am not convinced.

Furthermore, even before you are admitted to the hospital, usually you go through the emergency department and are seen by a doctor there – yet another transfer of care that could lead to gaps in information.  When you’re not feeling well, and if you don’t have a friend or family member to be your patient advocate, who knows you and your history, there’s no one to fill in those gaps.

When patient care is disjointed, responsibility for the patient can become murky.  It seems like the line would be as follows: when inpatient, hospitalist is responsible; when outpatient, PCP is responsible.  But liability issues arise because it’s not so simple.  Doctors are responsible for follow-up care.  Thus when discharged from a hospital should the hospitalist follow up? Yes.  But your PCP should too.  Without very close coordination of care, this can become tricky leading to miscommunications between the doctors, to you, to your family or others throughout your care in and out of the hospital.

About 80% of adverse events in hospitals involve communication problems between healthcare professionals, mostly from handoffs.  Poor communication may also mean redundant tests, prolonged hospitalizations or readmissions.  This includes communications between PCPs and hospitalists and between hospitalists when care is transferred during a patient”s stay.  Miscommunication is easy – we all know doctors have the worst handwriting, plus with complex medical problems details can be missed, and what about doctors simply being in a rush and not really taking the time to communicate to each other?  With all the physicians involved there is ample room for error.  (See this article by Dr. Parikh on  hand-offs)

In a silly analogous way, I feel like this sort of medicine is playing “hot potato” with the patient – passing the patient around from provider to provider for short bursts of care.  In the end, the PCP is “stuck” with you but what if someone drops you in between? Who has responsibility throughout it all, with your life in so many hands?  It troubles me that the responsibility is so spread out and there are many opportunities for things to get messed up.

(On a side note – quality measurements are a bit more difficult to attribute to each doctor.  Is the hospitalist judged on how the patient fares after discharge or if rehospitalized?  Is the PCP judge on the patient’s health while in the hospital or the patients health when following directions of a hospitalists upon discharge?)

There are other issues of liability that come with issues of responsibility for the patient – including issues of referral to a competent hospitalist physician by a PCP, scope of care issues, diagnosis issues, and patient abandonment.  There are issues that arise from tests not being preformed after discharge or test results not being shared before or after hospitalization.  Further issues arise in the way lawyers think about traditional liability in the hospital – are the hospitalists employees of the hospital? independent contractors the hospital is responsible for? or completely independent practitioners?  And then the ethical issue of a patient’s right to choose his or her provider.

Beyond liability, hospitalists fit in with interesting changes in medical care that I’m still hesitant to accept.  More and more physicians are choosing to be employed by hospitals instead of going into private practice as primary care physicians.  This is great for the doctors who have a steady salary, fewer working hours, and less financial risk.  (The New York Times had an interesting article about this last month.)  But this also means that there are fewer PCPs in the community, and we already have a shortage of PCPs.

Doctors working fewer hours is also an interesting trend.  I remember the horror stories of the shifts my father used to work as a resident – 100 + hour weeks.  That has drastically changed.  In 2004, residents were limited to 80 hour work weeks (don’t get me wrong, that’s still a LOT of time) partly because working so many hours seems cruel, but also in the hopes that medical errors would decrease.  But studies haven’t shown that doctors are actually performing better when they work fewer hours.  In the end, fewer hours whether as a resident whose hours are capped or as a hospitalist with set hours means more hand-offs between physicians.  You already know my misgivings about these hand-offs.

One more trend that makes me worry is the rise in hospitalists as we start to develop Accountable Care Organizations (ACOs).  I don’t want to go into too much detail here but I would just say that I have serious concerns over the conglomeration of hospitals and physicians.  ACO’s will allow hospitals and doctors to work together to work toward better outcomes and reduced costs.  It’s complicated but in the end it could mean many hospitals buying physician practices – leading to a more corporate medical care structure in my view.  It shouldn’t, but could limit choices for care.  And with more doctors employed by hospitals, as hospitals utilize more hospitalists, it just seems to me that all care will soon be centralized in a for-profit health care system run by huge organizations – the implications of which I am not sure I can fathom or would like.

On the whole, while I see the benefits of hospitalists, I still can’t quite accept them as better care providers for hospitalized patients considering legal, ethical, and other issues.

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2 Responses to Mixed Feelings About Hospitalists

  1. Hospitalist Victim says:

    The FDA and AMA will need to set guidelines for the use of tablets, particularly in ECUs, for the following reasons: 1) Ensure that treatment is evidence-based; 2) Require that a specialist such as cardiologist or neurologist is reviewing the EMRs or EHRs in-hospital; 3) Restrict hospitalists to only using tablets to research and not prescribe treatment. Let me describe an example of how the role of hospitalists is misused at Hoag Hospital in Newport Beach, CA that functions under PacificHospitalists.com. Pacific Hospitalists administered hyperthermia treatment to the paramedic’s use of Midazolam with side effects of decreased breathing, irregular heart beat, and amnesia. The hyperthemic-induced coma led to an 18-day hospitalized recovery and 20 lb. weight loss. Heart EKGs and spine and brain MRIs were all normal with no cardiac arrest, no blockage, no cardiomypathy, normal blood pressure, and no cholesterol. Hoag further preceding with implanting an AICD under the collaboration of Pacific Hospitalists Associates and the Newport Medical Heart Group. The lead physician at Pacific Hospitalists wrote a discharge report two days before actual discharge that included nine prescriptions included Lipitor despite low cholesterol. All nine prescriptions were cancelled by specialists as unnecessary or creating side effects. An administrator at Pacific Hospitalists stated that its doctors do not work with patients but only hospitals and insurance companies. The implication is that hospitalists using tablets will lead to selling unnecessary medical services by using either irrelevant or obsolete EMRs. In this example, United Healthcare UHC was the insurance provider who declined to review the work of hospitalists. UHC used the incident to try to cross-sell other unnecessary services like home nursing and prescription management. UHC was exploiting the employer’s insurance program from the out-of-guideline and non-evidenced recommendations of Pacific Hospitalists Associates.

  2. […] I once wrote how I had mixed feelings about hospitalists. My feelings are no longer mixed, I do believe their presence decreases quality of care and […]

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