Thursday, January 7, 2010

Hospitalists: complicating continuity of care

Whom would you rather take care of you if you need to be hospitalized? Your family physician who has managed your health issues for years? Or a complete stranger with specific training and expertise in caring for hospitalized patients? My medical school years (1997 - 2001) saw the rise of the "hospitalist" movement, a new physician specialty that defined itself as doctors who only cared for patients admitted to the hospital. This specialty has grown dramatically over the past decade, and is now represented by its own organizations, such as the Society of Hospital Medicine.

As a result, many primary care physicians have restricted their practices to office care only, which has financial (seeing extra patients in the time previously needed to travel back and forth from office to hospital) as well as lifestyle benefits (no more trudging in to the emergency room in the middle of the night to admit patients). A 2007 study found that patients cared for by hospitalists had a slightly shorter length of stay than patients cared for by general internists and family physicians, though costs of care were comparable between hospitalists and family physicians.

For the most part, this is a win-win situation for doctors and patients. But many office-based family physicians, including me (I stopped hospital work in 2008), feel that something valuable has also been lost in the transition - namely, continuity of care, the knowledge about a patient attained over years that can't be easily summarized in a brief admission note or even an electronic personal health record. In a recent piece in the Annals of Internal Medicine, Howard Beckman, MD, a former chief of medicine who subsequently stopped providing hospital care, relates the story of having a longtime patient hospitalized for breathing difficulty without his knowledge, until the patient's husband called him personally. When Dr. Beckman contacted the hospitalist on call to ask why a head CT scan had been ordered, rather than providing an answer, the hospitalist challenged him about the rationale for one of his patient's anti-anxiety medications:

The CT scan question was lost in my sense that I was viewed as the local medical doctor from whom the patient needed to be protected. At that moment, the lack of continuity in the patient's care seemed stark and disappointing.

Dr. Beckman goes on to describe how this lack of continuity, rather than being an isolated case, is in fact "the norm":

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.

Although the American Academy of Family Physicians has established guidelines for communication between hospitalists and primary care doctors, there is much anecdotal evidence that hospitalists often fail to consult a patient's personal physician to the extent they should. This is a tragedy that will likely worsen with health reform, as more patients who would otherwise end up in hospital emergency rooms are able to routinely access outpatient primary care services. There is no reason that physicians can't work together better to improve a patient's hospital experience and quality of care.

1 comment:

  1. Kenny
    I wrote about this (Dec 4, 2008, Hospitalists, http://medicinesocialjustice.blogspot.com/2008/12/hospitalists.html) and feel more strongly negatively than you or even Dr. Beckman.
    I do not think it is such a win/win except for the employer of the physicians who can have the "efficiency" of one full-time doc in hospital supporting several who never have to leave clinic.
    The measured outcomes in the studies you refer to not only show no improvement over family docs, but are done with very selected (e.g., Wachtter's UCSF) hospitalist groups; not the often doing-it-for-one-year-post-IM-residency-and-pre-fellowship hospitalists we often see.
    Most imporant is not a "soft" ense of oontinuity on the DOCTOR's part, but a real advantage to the patient of having a doctor who knows what they were like "before". I talk about it in the blog piece using my sister's hospitalization as an example, but I see it all the time.
    Not only does the hospitalist not know what your baseline was before you got sick, s/he may not even know what you were like yesterday, if you happen to be admitted at the end of the week. Heck, if you're in Thurs-Tues you could have 4 hospitalists! This is no joke; stories like Dr. Beckman's are very common.
    Sorry to go on so; I will stop; if anyone wants more, check out my Dec 4, 2008 piece.

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