Tuesday, August 9, 2011

Guest Blog: Why the hospital matters

David Loxterkamp, MD is a family physician who lives and works in Belfast, Maine. He has authored A Measure of My Days: The Journal of a Country Doctor (U Press of New England, 1997) and numerous articles for professional and lay publication. He is the Medical Director of Seaport Family Practice, which was one of 36 family practices to participate in the AAFP National Demonstration Project (2006-8) and one of 25 practices chosen for the Maine Patient-Centered Medical Home Pilot (2010-12). His new book on the transformation of primary care (Conversation, Friendship, & Hope: The Journey of a Country Doctor) will be published in 2012 by the University of Michigan Press.


Four years ago, Seaport Family Practice providers stopped caring for their hospitalized patients and gave up OB. Both services were an integral part of our practice for over 25 years.

There were compelling reasons for stepping back. We had tired of guideline-directed inpatient medicine and its narrow markers of achievement. Frankly, we were not as good at it as others who spent most of their day in that environment. We grew tired of the hierarchy, which is not surprising for occupants of its lowest rung. We just plain tired, too, of the night call that was required of those who maintained active membership on the hospital staff. We knew that most of our work took place in the office, even when we were performing the occasional delivery, attending the episodic medical crisis, or responding to an emergency visit in the middle of the night. With all of the new talk about patient-centered medical homes, we wanted to put our time and energy into advancing that cause, on whose success was pinned the hopes and survival of family medicine. That we were, first and foremost, a discipline of ambulatory clinicians was an easy argument to make. After all, that’s where our priorities should lie.

We knew that we could visit our patients any time we wanted to, although we never did, having allowed the hamster wheel to drive us with its own sense of urgency, its own unyielding momentum. Lastly, it was not hard to see that time in the hospital was financially irresponsible– slow and obtuse and unpredictable. It was much more efficient (a.k.a. lucrative) to pound out 25 office visits a day, see nursing home patients at our own convenience, and make home visits on our way to and from the clinic. Hospital CEOs and corporate executives also understand the calculus. With the majority of young graduates now preferring employment to ownership, most contracts do not include (or specifically exclude) the option of caring for inpatients.

But I missed doing it, and my patients missed me. There was a longing there that I attributed to an altered sense of identity. I had gone from being the doc who did it all to a more selective provider who did some. I had chipped off a piece of my generalist framework for taking in the world.

And 9 months ago I returned to the hospital as an experiment, n =1, to see if it really mattered to me or my patients, after all. The data set is not complete, but I can report on some preliminary findings:

1. Patients greatly appreciate it. Hospitalization often marks a dramatic reversal in a patient’s personal health. They are understandably afraid. The presence of a familiar face, an old friend, someone who takes time to talk and cares if they understand, let alone gives the patient his say, matters a lot.

2. The nursing staff appreciates it. They know that I am not there on business; I am there because I care about my patients. We have things to talk about. I listen to them, too.

3. The transitions of care go a little more smoothly. I can make sure that the medication lists between home and hospital reconcile; I can make sure that follow-up appointments are arranged for the next or most appropriate day. But I really don’t care if it prevents a re-hospitalization. Don’t get me wrong: I’m glad if it does, but sometimes patients need the hospital, or their own stubbornness puts them in harms way, which to the inevitable, or we all miscalculated the degree of need. It is not my fault that the hospital is so expensive, so I don’t make fixing it my top priority.

4. Lastly– and here’s the surprise– I have something to learn there, and I have something to teach. Hospitalist and ambulatory physician alike operate within a limited field of vision. We both make assumptions and decisions based on our varied training, experience, and perspective. We seldom (read that “never”) take the time to let the other know when a different decision would have led to a better for the patient, preferring instead to remain smug, distanced, and annoyed.

I know it's not easy to overcome the mutual defensiveness, embarrassment of being wrong, and fear of legal reprisal that is so endemic in modern medicine. But without the effort, our patients suffer, and we never learn. It is now commonplace for hospitals and practices to implement elaborate protocols at the time of discharge, often overseen by well-meaning nurses who have been renamed as “care managers.” But they are following protocol. They are not bridging the intellectual gap, the collegial gap, between hospital doctor and his outpatient counterpart.

Without the two sides talking on equal footing, neither side listens, neither side learns. We are losing opportunities to do what is right for the patient. Instead, we simply respond to payment incentives that punish hospitals for readmissions. We are following the dollar. We are not following the age-old family medicine directive to “do the right thing.”

Not every family doctor needs to be in the hospital, or deliver babies, or make home visits, or perform colonoscopies, or provide addiction treatment. But someone in his or her practice does. Or should, for the good of their patients, and for the completeness of care that their practice should provide. We are, after all, generalists. We must work hard to guard that mantle, and to emphasize the importance of human relationships across the professions, and follow our unflinching desire to do what is best for the patient, no matter what it costs in our, or someone else’s, time and money. This is why I think hospital care should matter to family medicine, from someone who has seen it professionally from both sides now.