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    Hospitalists, PCPs bad at communication and its hurting patient care

     

    It is unfortunate that the nursing home nurse did not call the patient’s primary care physician upon transfer, but it was even more unfortunate that her PCP was not contacted at any time during her emergency room stay or subsequent hospitalization by any of the doctors who saw her. Had they called Mrs. P’s PCP, they would have learned that she had a long history of progressive dementia and similar unresponsive episodes in the past that had been fully evaluated. Further, they would have learned that she always carried bacteria in her urine without tissue invasion and that she could have received any of her treatments in the nursing home where she would have been safer and more comfortable, at a far lower cost. A recent study showed that 20% of hospitalized patients who receive antibiotics develop an adverse event, so avoiding unnecessary antibiotics must be a top priority.

     

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    The growth of the hospitalist movement over the past twenty years has been truly phenomenal—at 50,000 physicians, it is the largest medical sub specialty, surpassed as a specialty only by general internal medicine at 109,000 and family medicine at 107,000. Studies suggest that quality was improved and costs reduced with hospitalist care. This was especially true for complicated patients who required multiple physician visits and interactions each day, something increasingly difficult for the community-based PCP to achieve.

    The hospitalist is experienced in managing the types of medical issues that lead to hospitalization and works full time in the hospital. As a result, they come to know how to “get things done” and potentially can give more efficient care. But they are far too often burdened with large numbers of patients, and often know very little about the patients they are treating. With too many patients to care for and too little information, they tend to request consultations for problems that, given adequate time, they could have managed. This is especially problematic if the patient has multiple medical issues and is elderly. Other reasonable concerns are the diminishment of the patient-physician relationship and miscommunication and discoordination at both admission and discharge. Communication with the patient’s PCP could alleviate many of these issues.

     

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    PCPs have been generally content to allow the hospitalist to manage their patients; indeed it has been a major advantage for many. PCPs have seen their overhead costs rise dramatically, necessitating seeing more and more patients per day for less and less time each in order to cover those overhead costs. The multitude of rules, regulations and requirements foisted upon them by the insurers has further consumed extensive time—time that previously could be used to care for their hospitalized patients. Today, many PCPs do not have time to see patients in the hospital, while others are barred from doing so by hospital rules.

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    Andy Lazris, MD, CMD
    Andy Lazris, MD, CMD, is a primary care physician whose private practice focuses on geriatric patients, especially those residing in ...

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    • Anonymous
      Thanks for such a nice article, Dr. Schimpff. Our team at Medssenger agrees with problems and vision discussed, and we have developed a cross-platform app that could serve as a solution. Not only does Medssenger enable communication between hospitalist and PCP, we support coordination and full-on workflow among the two. We go across transitions of care and organizational boundaries, automatically managing workflow to completion. We look forward to contributing to better health care, and we will continue to follow your articles and books.
    • Anonymous
      10 years back pay. Remove EHR. Remove HIPPA. Remove regulations. True Tort reform. Let the Physician walk the hall and run the show like it's suppose to be. The way we say it should be. Let them decide the regulations with true peer pressure. When I was in school I would've done anything to make it the best for patients as the peer review was unlike any other force around. The insurance companies and Medicare have billions. Let them figure out how to pay fee for service. That's what will fix the system overnight. With privilege comes responsibility. It's the only way it will work.
    • Anonymous
      Very true example given. To start with there is a philosophy in hospitalist thinking that every "problem" needs a complete workup. Just like in this case bacteuria (most likely NOT from a cath specimen) was worked up and treated. Probably a false positive from collection technique. As a gyn I can't tell you how many times I was consulted for a "yeast" infection to see a patient in a hospital that didn't even have an exam room to do a pelvic exam. The other problem of course is Uncle Sam. There was a time that the primary care doctor was the center of all treatment but that was before when they were still paid to make rounds on their hospitalized patients. No longer such and therefore no continuity of care. Most PCP no longer have hospital privileges. The other issue is that the hospitalists are frequently seeing 10 or more NEW patients with complicated problems each day in addition to making rounds on the patients they already had. An impossible task to follow through on. Treat the abnormal lab and use specialists as extensions. And of course on the following day a new hospitalist is on call. Finally there is the failure of the nursing home. Dump the patient into the hospital on every chance possible. My MIL, 92 years old, is in a nursing home now. No transfer to a hospital without our permission no matter what and she is under DNR rules. I really don't blame the hospitalist as they are behind the eight ball here. I really think that the PCP is at fault. For so many years they wanted to be treated as the center of all care and then they dropped the ball. When I operated on a patient I made rounds every day until the patient went home and then followed them up post-op. No extra pay for the rounds even if it meant months of visits. PCP's decided that it was not worth fighting for with Medicare to get paid and that if they weren't getting paid they were not going to see their patients. So sad. Glad I am retired.
    • jpowell@------.com
      Dear Dr. Anonymous, I disagree with your comment that "the PCP is at fault". I am a family physician with over 22 years of private practice experience. I still continue to practice inpatient and outpatient medicine. There is plenty of blame to go around as to why the system is breaking down. However, I can assure you that greed on the part of family physicians is the least likely explanation. We did not "drop the ball". The "ball" got dropped on us. You are a retired OB/GYN and not a "PCP" so you really have no idea what kind of wrecking ball exists today in the form of patient metrics, regulations, insurance hassles, paperwork and unrealistic patient expectations (last internet search) that are thrust on the family doctor. When you practiced OB, I believe nearly 50 percent of medical school graduates went into a primary care practices, today, it is less than 25 %. Now, look at U.S. demographics, we are getting older. It is a pretty simple diagnosis really. There is more work to do. There are fewer physicians and new medical graduates willing to do it. It is harder to wade through the bureaucracy to get the job done.There are more medical management options for the primary care physician to consider.The lack of collegiality and condescending attitudes from some academics and specialists do not help solve the shortage of primary care physicians either. Your statement, "if they weren't getting paid they were not going to see their patients" referring to primary care physicians is unfortunate and as you say, sad. I hope that our primary care thought leaders and medical societies will avoid being complicit with insurance, government and hospital programs that sabotage the primary care physician's effort to care for our patients. In the meantime, I will develop systems that work for our group and patients. I would just like others that do not really know what the day of a family physician looks like to stay out of the way.
    • m.brumberg@------.net
      What I am and what is really disappearing in medicine is the era of the solo practitioner. It has become very difficult to continue to be the jack of all trades and all things to all of your patients as what used to be the case or so it was believed by many of our breed. The era of the Mom and Pop family practice is just about over. Obviously medical care has evolved into a cacophony and not a symphony of instruments each one trying to become the voice of the whole and solo family practice has become the orchestral triangle drowned out by the much larger and much louder instruments around it. We have been boxed out of hospital care, boxed out of nursing home care, relegated to a position not that of GATEKEEPER but that of DOORMAT. Insurance companies, the government, the legal profession and yes even organized or is it disorganized medicine are culling the herd of the once mighty species much as the sharpshooting hunters did to the buffalo who once roamed the plains in the millions until they came up against the rapid firing Winchester rifle. It is hard to say goodbye to a profession to which you gave your "blood, toil. tears and sweat" for many a year. At some point in the not to distant future things will probably settle down and doctors, nurse practitioners, physicians assistants and others will find or be assigned their particular niche until the next major development in medical care emerges; that of TOTAL COMPUTERIZED ROBOTIC MEDICAL CARE and SURGERY with little or no human involvement. Are you listening Stephen Hawking?

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