Hospitalists and Community Physicians- It’s All About the Handoffs

I referred my second patient to a specialty surgery department at a local university center last month. The patient is a practicing physician with severe lower back disc disease and structural abnormalities. He saw a highly acclaimed surgeon who won the patient’s confidence.

I performed the required preoperative evaluation requested by the surgical team, called the surgeon to make sure we were on the same page, and made sure all the appropriate records and labs arrived at the center prior to the patient’s surgical date. Three days after the scheduled procedure I received a phone call after-hours from a nurse at a local rehabilitation facility telling me my referred patient had been transferred from the university center after discharge and requesting confirmation of  admitting orders to their facility for postoperative rehabilitation.

I had not received a phone call from the surgeon or his staff to discuss how the surgery had turned out. I had received no phone call, fax or email telling me when they planned to discharge the patient. I received no communication discussing discharge instructions and medications.  The surgeon is a chief of a department responsible for teaching fellows, residents and students how it should be done. He fumbled the handoff and sent a patient on his way with a bunch of handwritten chicken scratches on a form filled out by a case worker. In the era of cell phones , smart phones , email , faxes , instant messages and tweets it seems like communication between practitioners has gotten worse not better due to lack of effort and failure of practitioners to acknowledge that it is their job to take the time to make the transition smooth and seamless.

The hospitalist program at my community hospital is no better. Physicians employed by the hospital were supposed to “move “patients and facilitate discharges helping the hospital’s financial “bottom line.”  Hospital administration contracted with non-fellowship trained hospitalists to admit patients who arrive through the ER and have no doctor. The hospitalists are only too happy to admit patients of staff members who do not wish to attend their patients in the hospital.

The problem is that the hospitalist do not enjoy coming in at night. When a patient with a hip fracture shows up at our ER, the orthopedic surgeons on call for the ER now believe they are consultants not doctors. They will not admit a surgical case. They want the PCP or hospitalist to do it for them. If a broken hip case arrives after 7:00 p.m. “the hospitalist “admits the patient sight unseen over the phone and then comes in by 7:00 a.m. to see the patient.

Our hospital has some patient unfriendly bylaws. If the ER doctor calls you and says your patient requires admission you have 30 minutes to provide admitting orders over the phone or in person but you have 12 hours to arrive and actually see the patient.  Showing up 12 hours later often pushes the surgery back a day negating the main reason hospitalists were hired. When the patient is ready to leave the hospital it is rare that the facility has introduced the patient to an outpatient physician for follow-up care.  If the patient actually has an outpatient physician it is even rarer that the hospitalist contacts them to discuss the hospital course and discharge medications and instructions.

The system in the Intensive Care Unit is no better. After years of debate and disagreement based primarily on economic issues and turf and privilege battles, administration contracted with a pulmonary group on staff to provide fulltime intensive care physicians. They went out and hired a bunch of young ICU specialists and salaried them.  These physicians run the critical care areas.

I have always favored fulltime ICU physicians in our community hospital because with no interns or residents there are no physicians in the facility after hours. I was a bit surprised when the contract allowed the ICU doctors to go home at 11:00 p.m. leaving no one in the units until the next morning. My first contact with the intensivists came after a weekend away during which my associate covered for me.  He admitted a patient to the hospital with a raging pneumonia.  Since the patient was taking an anticoagulant Coumadin he had to specifically choose an antibiotic that didn’t alter the affects of the blood thinner. Later that first night the patient had some respiratory distress so my associate came in and transferred the patient to the ICU. He called the intensivist and discussed the case in detail.  He made rounds the next day and reviewed the chart and pointed out to the ICU specialist that the antibiotic he had switched the patient to potentiated the Coumadin effect. He suggested checking the clotting study and adjusting the dose of the Coumadin.

When I came in on Monday I found the patient lying in a pool of blood from the rectum. His PT/INR had been elevated the day before and required lowering the Coumadin dose. No action had been taken. His PT/INR on Monday was even higher.  I called the charge nurse and barked out some orders. She reminded me that the intensivist was in charge. The intensivist that morning was a young woman in her early thirties. When I asked her why the monitoring of his Coumadin dose was left unattended she took great offense and answered, “I wasn’t on call this weekend, why don’t you take it up with the doctor on call.  He’s asleep now so I would give it a few hours before you call him.” I gather she wasn’t willing to “take one for the team.”

Within the last six months an editorial in the Journal of the American College of Physicians was critical of hospitalist programs for the poor communication when a patient leaves the hospital and returns to his doctor in the community without communication occurring.  A recent research article in the same journal revealed that patients treated by hospitalists require re-admission to the hospital for some complication of the original problem far more often than if their personal physician cared for them. The ultimate cost to the system was higher. The problem is the communication and handoffs.

Part of the problem is that physicians no longer feel it is their responsibility to contact their peers. In the past, physicians had close knit referral circles and patterns using physicians they trusted and worked well with. Insurance company managed care programs destroyed those referral patterns forcing physicians to use the doctor on the panel or else they would not pay the bill. Often the consulting doctor on the panel was resentful of receiving a consult from a doctor who had never used his services but would now use them at the panels discounted rate. They felt no strong compulsion to contact the referring physician and discuss the case. T

The referring physicians are not without blame either, often sending patients to physicians they have little contact with accompanied by little if any information as to why they were being consulted. A culture of communication and sharing of information professionally became a culture of “I am too busy to make a call.” The one that suffers is the patient and the people paying more for care because of communication breakdowns.

The American Medical Association and the American College of Physicians have supported the development of the specialty of hospital medicine long before I believe they should have. These organizations are heavily dominated and supported by specialty physicians who are paid handsomely to stay in the operating room and perform procedures rather than care for the patients.  Having hospital employed physicians to be their “scut “workers and take care of the patients with their nurse practitioners and PAs makes sense to them. It breaks the link of good continuity of care and just isn’t very good for patients or overall costs.

Legislators, politicians, employers, insurers, medical school faculty keep looking for ways to overcome the shortage of primary care physicians and the large gap in payment between cognitive services and procedural services. The solution to the problem is to pay the primary care physicians well for their evaluation and management services, train them thoroughly and completely and allow them to care for their patients in all our health care venues.

Who Says Concierge Practice Is Unjust For Patients And Doctors Alike?

Medscape Medical Ethics published an article in August 2011 written by Art Caplan, PhD., Professor of Bioethics and Philosophy at the University of Pennsylvania claiming that Concierge Practice Is Unjust For Patients And Doctors alike.  A PDF of the article is attached for your review.  Concierge Practice Unjust For Patients and Doctors Alike by Art Caplan, PhD.

I am in disagreement with Mr. Caplan’s article.  Below is my perspective.

Like the shots fired at Concord and Lexington in 1776, concierge medicine and direct pay practices are the initial shots fired by concerned primary care physicians in the revolution against health care systems which limit access to physicians and destroy the doctor / patient relationship. Concierge medicine arose as a result of government, private insurance, and employer intrusion into the health care field destroying primary care and a physician’s ability to spend the time required with patients to adequately and comprehensively prevent and treat disease.

The only thing that is unjust or unethical about concierge and direct pay practices is that they had to be formed to begin with. They formed after 30 years of:

  1. Primary care doctors lobbying unsuccessfully for adequate compensation for evaluation and management services and for protesting the widening gap between cognitive services and procedural specialty practices.
  2. Going through channels protesting the unfair bureaucratic and administrative burdens placed on primary care practices by Medicare, Medicaid and private insurers.
  3. Warning that the population is aging and their chronic health care problems are far more complex requiring more time with a physician rather than less.
  4. Primary care physicians leaving medical practice for early retirement or for paid jobs with pharmaceutical companies, medical device manufacturers and hospital administrations where hard work and achievement were rewarded without having to deal with system imposed overheads of up to 65 cents on the dollar.
  5. Legislators providing no relief from frivolous lawsuits which makes seeing complex patients in 5-10 minute sessions for “single problem directed visits” a legal liability.
  6. Medical students realizing that the time and financial commitment to the practice of primary care medicine didn’t cover the bills essentially directing them toward more lucrative procedure dominated specialties.

Physicians also left after salaried academic physicians, who never took risk and invested a cent of their own money in building a practice, pontificated and moralized in peer journals supported wholeheartedly by biased pharmaceutical company ads that generating passive income through shared labs and imaging centers was a kickback.

If we look at the data accumulating on care from concierge and direct pay practices, we find that despite a sicker patient population these practices generate fewer visits to emergency departments and fewer acute emergent hospitalizations saving the system money.  These practices provide coordinated care for their patients steering them through a complex and confusing health care system riddled with inappropriate advertising and claims and, get the patients to the best people to treat their problems.

Concierge physicians have more time to spend with their patients thus, achieving unheard of levels of retention and patient satisfaction while giving pro bono scholarships to patients who cannot afford their membership fees but were with them prior to their conversion to a retainer model.

After years of being on the conveyor belt of having to see more patients per day, every day, to stay abreast of system generated overhead cost increases and declining payment for services, concierge physicians now have time to teach students, volunteer at health fairs and screenings and participate in the stewardship of what remains of their profession.

If anything is unjust and unethical it is salaried academic non-physicians writing articles about morality and justice about issues they have no hands-on experience practicing. As a primary care physician for 32 years, I feel like a chameleon having to change colors and practice style every few years based on new rules imposed by private insurers, employers and government programs. At no time were these new rules designed to improve the patients’ access to care or total care.  In each case the new rules were designed to save money and do nothing else.

Concierge and direct pay medicine is the first volley in a revolution to take outstanding care of a smaller panel of older sicker patients on a long term basis.  Its proponents have worked hard for decades to change the system through channels. Failure of legislators, government bureaucrats, health insurers, employers and professional associations such as the AMA and the ACP to react and fix the inequities has generated these practices which cost less than a cup of Starbucks grand latte per day to be a patient of and provide comprehensive care and access.