Blog | Thursday, April 24, 2014

Do hospitalists improve or detract from quality of care?


Editor’s Note: This column originally appeared in 2 parts at MD Whistleblower.]

Part 1

Hospitalists are now firmly planted in the medical landscape. These doctors have no office practices and earn their living exclusively by managing hospitalized patients. These guys and gals are either hospital employees or are private groups who are under contract by hospitals. The market and the profession were hungry for this new specialty, which has exploded across the country. The advantages to patients and to practicing physicians are enormous. Are there drawbacks?

When these hospital physicians first appeared on the hospital scene, there was buzz that patients would push back against these stranger-docs wanting their own office doctors to attend to them instead. This never materialized. Patients no longer had the expectation that their own doc would be available to them 7 days a week. Indeed, medical physician groups and institutions had on-call rosters such that it was likely that the doctor available was not the patient’s actual physician. So, the heavy lifting had already been done.

Once patients and their families recognized the high quality of care that hospitalists provide, whatever doubts that may have existed evaporated.

Here’s the upside.
• Hospitalists provide superior hospital care because of their training and experience. It is probably true that a physician who treats 75 heart attack patients each year is more skilled at doing so than is a family doctor who does this quarterly. In general, higher volume translates to higher quality.
• Hospitalists are there around the clock. They are available to check on patients throughout the day and night. Can anyone argue that this is not superior to the prior system of the attending physician seeing the patient once daily? Go ahead. Make your case.
• Hospitalists allow primary care physicians to stay clear of the hospital so they can focus on their out-patient practices, where their skills are better matched. Additionally, it is very inefficient for a primary care physician to come each day to the hospital to see a patient or 2. For these reasons, the vast majority of primary care physicians refer their hospitalized patients to hospitalists for care and treatment.
• Internists enjoy a higher quality of life as they no longer have to stagger in at 3 a.m. to admit one of their patients.

Part 2

There is the Achilles’s heel of the hospitalist system. While the advantages are clear and substantial, there are serious vulnerabilities which have not yet been adequately remedied.
• Hospitalists cannot appreciate the medical nuances, personality, family dynamics, life events and prior experiences that may be well known by the out-patient physician.
• There are serious communication lapses, all of which cannot be bridged. The out-patient doc may know that the patient’s chest pain is his typical anxiety and that it is not necessary to repeat the cardiac evaluation that was done 2 years ago. The hospitalist may take a different tack here.
• Despite their best efforts, hospitalists know that they will not be seeing the patients after discharge. As they are not permanently vested, they may not address certain patient concerns, punting these to the outpatient arena. While this may be medically acceptable, it may be frustrating for some patients.
• The hand off back to the out-patient doc after hospital discharge can be a minefield. Patients may be on new medications. They may have had a variety of laboratory and radiology tests. Some of these results might be ‘pending’ at the time of discharge. How does the out-patient physician reliably receive these results and understand their context? Did medical specialists on the case leave recommendations that the primary physician now has to track and implement? When the primary care doctor resumes care of a patient who had a complex hospitalization, is he now responsible to search out and address every loose end contained within the voluminous hospital record? Could a single laboratory abnormality buried in the record that was totally unrelated to the medical illness become a medico-legal issue years later? Do we really think that the hospitalists discharge summary to the primary care physician is airtight?

A primary care physician recently complained to me that the local hospitalists never call him when his patient is admitted when he might provide useful information about his patient that only he knew. This is a legitimate gripe.

No system is perfect.

So, which side of the issue has the better argument?

This post by Michael Kirsch, MD, FACP, appeared as part 1 and part 2at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.