Continuity of Care Threatened by Deteriorated Communication Between Hospital-Based & Community-Based Physicians

Medicine in my area of the country has morphed into physicians who care for patients while they are in the hospital  as “in patients” or “ observational status” and outpatients.  Very few primary care physicians admit their patients to a hospital and then care for them while hospitalized. There are numerous reasons for this, mostly economic and initiated by hospital administrations and insurers, but that will be the topic of a future discussion.

In today’s healthcare environment, most hospitalized patients are cared for by hospitalists. These are physicians, nurse practitioners and physician assistants either employed directly by the hospital or employed by a group practice that is contracted to provide services at that facility.

My role as a primary care physician is to present the hospitalists with the reason why the patient is at the emergency department with past records and to provide them with the perspective needed to provide continuity of care. If I know my patient is going to the Emergency Department, I phone the ER charge nurse , review the patient’s case and ask to speak to the physician who will be evaluating them. After I have completed those two calls I send over the records via fax. 

Sadly, the ER physician I have spoken to is often not the ER physician who sees the patient. Also, the records I fax to the ER frequently are not added to the patient’s chart nor are they provided to the ER physician even though I have received electronic confirmation that they were received.

I have arranged to have one coverage team of hospitalists see my patients requiring hospital admission. I text or call that physician to alert them that a patient is on the way.  Unfortunately, the Emergency Department doesn’t always call that doctor to see the patient. In those instances, they admit the patient to the hospitalists resident team instead. I have had numerous phone calls and meetings with the hospital CEO, hospital chief medical officer, the physician leader of the emergency medicine group employed by the hospital and the head nurse in the ER regarding these issues.  My name and the covering physician’s name are clearly listed in their computers and they discuss it at staff meetings but somehow patients frequently end up on the wrong team.

As part of the hospital admission process, the patient’s primary care doctor in the community, and specialists, are usually mentioned in the information obtained upon arrival. That information is certainly included in the documents I send over to the facility. Despite this, it is rare to see a patient admitted to the resident program hospitalists program actually notify those specialists or ask them to see their patient. I call those specialists to make them aware of our mutual patient’s hospital admission so they know to stop by and check on the progress of our patients. 

I use the computer portal daily to follow the evaluation and treatment of these patients. If I have questions or concerns, I speak to the hospitalist physician about it. Upon a patient’s discharge from the hospital, I receive a fax notification from hospital administration notifying me that the patient has been sent home.  I access the discharge summary, print it out and place it in the patient’s office chart and update the medication list if changes have been made in the hospital. For this to be thorough and complete the process requires the hospitalist dictating the summary to be thorough and complete. Sometimes this occurs.

Take the case of Kathy, a 63-year-old woman born with cerebral palsy and suffering seizures.  Since her parents died, she is living with a caregiver supervised by a family member who makes all the medical, legal and financial decisions with the patient supported by funds set aside by her late parents. For unknown reasons, she tragically has had a series of uncontrolled seizures and is taken to a hospital not in my service area. To control her seizures required sedating her, intubating her and putting her on a ventilator to breathe while sedated. While unconscious from sedation she had an arrhythmia requiring starting a new medication to control the rhythm and an anticoagulant to prevent a clot from forming in her heart and traveling to her brain causing a stroke.  Her neurologist and heart specialist were never notified by that facility’s hospitalists even though they had partners who routinely visited that facility. 

Upon discharge, the hospitalist prescribed two days of the amiodarone for the new rhythm and two days of the anticoagulant Eliquis.  They suggested seeing the cardiologist for follow up but the soonest his office could see her was five weeks away.  The discharge summary made no mention of the arrhythmia. The discharge summary did not list the amiodarone or Eliquis.   

The patient’s legal guardian called me to ask about the lack of medications prescribed and basically to have someone explain to him what had occurred. To clarify the situation, my staff contacted the medical records department of the hospital and faxed them a signed authorized medical release of records . We obtained all the daily progress notes and consultation reports. These documents provided the name of the cardiologist who saw her.  It took several attempts by phone before we reached him and he explained what had occurred and clarified what dosage of amiodarone and what length of treatment he preferred and why.   

This research and clarification took hours of non-compensated time.  It was an absolute necessity to insure safe care for the patient. General internists, family practitioners, pediatricians do this daily attempting to coordinate patient care . The lack of interest by hospital administration and overworked employed hospital physicians and staff make being successful increasingly difficult.  The lack of outrage over these incomplete and lazy handoffs is infuriating.

The same families that are furious at the care they receive donate charitable funds to these institutions with few, if any, strings attached about where the money is needed and should go. With for-profit hospital and medical facilities behaving no differently than non-profit facilities and medical groups, and no pressure from the IRS, Center for Medicare Services or insurers, I see no hope for a more professional and thorough handoff of care between the community physicians and hospital-based care.

Has the Business of Medicine Ruined Health Care?

Early in my career if I had an elderly patient recovering from an illness or surgical procedure and their condition required an extra inpatient hospital day, I just looked at the chart and found some chronic condition still not “normal” . I wrote a note in the chart documenting it and the patient stayed put. Most of the time the reason was medical. Sometimes it was logistical, such as a family member flying in to be the caregiver and unexpectedly delayed. Sometimes it was about a hospital bed or wheelchair or nebulizer unavailable until the next day. I deferred to caring and compassion.

As we moved into the 1980’s and 1990’s, and managed care evolved, a new hospital employee position replaced the “social worker” called a “ case manager”. They would discuss “ Length of Stay or LOS” and tell us reckless spenders how much we were costing the hospital. This didn’t jive ever with the annual financial report card I received from that facility  in the first quarter of each year on patients I cared for while hospitalized. There was not a year where I had not made the facility at least $250,000 in profit and that was only from the inpatient data. I kept a copy of that report with me when I made rounds and, as an independent practitioner not employed by the institution, I had the ability to put my patient first and remind administration each time they complained.

I bring this up because I read an article in the New England Journal of Medicine this week written by a young physician complaining about how the hospital employed physicians discharged patients routinely before their evaluations were complete. He cited examples of how this practice delayed the diagnosis and life span of the patients. The author felt great compassion for the patient and the hospital based employed  physicians who are under tremendous contractual pressure to discharge quickly and keep the admission profitable. This is occurring in for-profit hospitals as well as in  not-for-profit hospitals.

At the same reading session, I read an article discussing the problems that occur when an older adult is admitted to the hospital for an illness which the authors, in retrospect, believe could have been handled while the patient stayed at home. In 40 years of practice, I know of no situation where a patient who could safely stay at home was hospitalized for physician profit.

Do you have any idea how inconvenient, inefficient and cost ineffective it is  for a physician with an office-based practice to care for a hospitalized patient ? You have to get there before daily office hours, return after office hours and handle dozens of phone calls from nurses, aides, pharmacy staff and physical therapists – not to mention family members.

“The suits”, business investors, insurers and employers, plus CMS and our elected Congressional officials, have cut the heart and caring out of medicine. I stopped going to the hospital at the  start of the pandemic when hospital officials limited who could see patients as a means to slow the spread of infection. When it was considered safe to return to the hospital, the control of administrators over care decisions had expanded so much that it was clearly uncomfortable to work there.

My physician partner, who covered my practice when I was out of town or ill, refused to  return to hospital care for just this reason. It left me without backup.  I explored returning but the care and concern by hospital staff were so different and so robotic I felt that if I returned I would end up in a shouting match trying to advocate for my patients and lose my credentials anyway.            

My local hospital was built because emergency care was not available for two youngsters who died enroute to a distant hospital in the early 1960’s. The facility was built by the community and recently sold to a major not-for-profit chain. Just prior to the sale, they  closed its pediatric unit because it  was not  profitable. However, they continue to have a profitable labor and delivery program and continue to deliver babies. If those newborns become ill they are sent to hospitals 35 – 40 minutes away. If a child is brought to the Emergency Room and requires admission to the hospital, they too are transferred to a pediatric unit in Broward County or the one in Palm Beach. This is what occurs when financial people run healthcare.

The influence of ‘ business” on medicine has even infiltrated into medical schools where students are encouraged to become employees and work shifts for balance of life reasons rather than enter their own private practice and develop lifelong professional relationships with patients.

An article from Canada talked about the importance of primary care in treating chronic illnesses. With an aging population of baby boomers, preventing and controlling chronic problems is essential to the health of the citizens and the financial health of the country. 

In Canada, with a national health system, less than 1% of the caregivers are nurse practitioners or physician assistants. You are evaluated by and treated by a physician. Hospitalists( hospital-based and employed physicians) were the creation of a bunch of residents at University of California San Francisco who, upon completing their training, had no idea what to do with their careers. Their mentors in academia detested their time away from their research while out on the wards supervising the care and training of internal medicine physicians. They hired these doctors to perform their clinical duties and responsibilities so they could continue to teach and conduct research. Hospital administrators loved the concept because by employing them and making it difficult for community based independent physicians to come to the hospital, they had a mechanism to control costs and length of stay. Insurers and employers loved them for the same reason. Nurse practitioners and physician assistants were adored for the same reason.

Hiring a “mid-level” provider is far less expensive than hiring a physician. The original wave of NPs and PAs came from experienced nurses with years of  experience in the field. Bringing them back to school for training and then supervising their postgraduate clinical experiences produced some outstanding clinicians. The new breed of mid-level providers come from students with two years of experience only. While a physician in training is supervised for a minimum of 144,000 hours, the oversight on mid-level providers is far less. Asking them to be the chronic care supervisors in the USA may help the bottom line of insurers, employers and hospital systems but it does little for senior citizens.

My advice to patients is simple.  Find yourself a well-trained independent physician who actually sees patients. Stay away from HMO plans unless it is a superior product like Kaiser Permanente. Stay away from Medicare Advantage plans. They are not the same as traditional Medicare. They cost less for patients but the price you pay if you get ill in terms of choice of physicians to care for you and facilities can be very limited.

If you can afford a concierge physician or direct pay physician with a small practice it is well worth it.  If you get hospitalized you need a savvy advocate who knows health care to be there with you.  Write your Congressman and advocate  against Medicare Advantage plans which actually cost more per patient now than traditional Medicare. If your care is switched to a mid-level provider, ask that provider how much clinical experience they had in nursing prior to entering NP or PA programs. Scrutinize them the same way you would view the credentials of a perspective physician. Lastly, ignore their online reviews. In general, online reviews are written by patients who are dissatisfied and don’t necessarily represent the overall sentiment the majority have of the provider.

Hospital Discharges and the Handoffs

Fred Pelzman, M.D. is an experienced internist who practices in the NY Metropolitan area and trains young doctors at a well-deserved renowned academic medical center. His corporate behemoth medical system tries to engage in the latest and greatest business practice models for care, using technology and staff generally unavailable to the mom and pop medical practices that once dotted America.  Meanwhile, Dr. Pelzman cares for people compassionately while training his young disciples in an ever changing and complicated health care environment. I love reading his blog posts discussing his thoughts, concerns and efforts.

This week’s article or “post” is about the difficulty and danger entailed when a patient leaves the hospital, after being cared for by hospital based physicians, and returns to their homes and the care of their outside doctor’s. I give Dr. Pelzman much credit for taking ownership of the problem and attempting to solve it. I think there is a much simpler solution to his problem than creating a fast track computer program for patients who need to be seen quickly post discharge. It is called the telephone.

There was a time when physicians actually picked up the phone and called their colleagues and discussed the transfer of care before initiating it. During my internship and residency at the University of Miami Jackson Memorial Program; when a patient was being transferred, the receiving physician received a page resulting in a phone call from the transferring physician to discuss “the case.” The transferring physician wrote a transfer summary in the chart to be reviewed by the receiving physician. When patient’s went home, especially non-private patient’s, the handoffs were inadequate since often there was no receiving physician to communicate with.

After finishing my training and entering private care in a suburban community, the transfer of care was quite simple because most physicians cared for their own patients in the hospital and in the community so the transfer of care was smooth and seamless. This changed with the institution of “managed care” run by insurers at the request of employers and by the development of hospitalist physicians.

Employed hospital based physicians were the idea of Robert Wachter, M.D., the father of hospitalist medicine and the current director of hospital physician training at University of California in San Francisco. When he was completing his training in internal medicine he noticed that general internists in private medicine were not being paid very well in the field. He also noticed that his academic teachers, who were required by Medicare and insurers to actually spend time taking a history, doing a physical exam and writing a progress note on each patient on their teaching service if the facility was going to get paid for their care hated actually interacting with patients. They preferred to be in their research labs or teaching students and future doctors.

Hiring someone to do that work and creating a specialty gave them the freedom to go back to what they wanted to do. It also gave administration a certain amount of control over the tests ordered, medications ordered, length of stay and costs. At the same time this was occurring, “administrative and management experts” were out in the community, convincing private physicians that the solution to their low reimbursement was to stay in the office and see more patients and give up caring for hospital patients. It was deemed inefficient to cancel or delay patients in your office or clinic so you could run to the hospital or emergency room to see an acutely and seriously ill patient.

As hospitalist medicine took hold, medical and surgical specialties decided it was more efficient to use their services than to take the time to admit the patients with issues they were best trained to care for. Orthopedic surgeons stopped admitting patients to the hospital with fractures that needed surgical repair. They asked the hospitalist to do it. Oncologists stopped admitting patients with fevers and infections and abnormal blood counts as a consequence of their cancer or treatment of cancer. They asked the hospitalist to do it. Gastroenterologists stopped admitting acute gastrointestinal bleeders who needed endoscopy and cardiologists stopped admitting acute heart failure and pulmonary edema and heart attacks. These specialists preferred to be “consultants” and let the hospitalists perform the tedious medication reconciliation, admitting orders and mandated quality metrics forms and the deep vein thrombosis prevention forms. The hospitalists became their interns and medical students performing the time consuming , bureaucratic, labor intensive low paid administrative work so the specialist could arrive like the cavalry and just do their procedure and leave.

The problem is that the hospitalist didn’t know the patient. The referring doctor never called the hospitalist or ER physician to send the records and explain why the patient was coming and there was little if any communication. The same occurs when the patient leaves the hospital and is sent for post hospital care. No one coordinating care in the hospital contacts those responsible for the patient’s outpatient care to discuss a care plan. The fault lies with both the inpatient and outpatient physicians who don’t take the time to communicate.

Above anything else, the patient must come first. Picking up the phone and calling the receiving physician and discussing the nuances of the necessary care and creating a plan which is explained to the patient is in the patient’s best interests. All care givers need to remember this and create local environments, climates and systems that encourage communication between hospital-based physicians and community physicians.

Primary Care Docs Outperform Hospitalists …

A study published recently in JAMA Internal Medicine looked at 650,651 Medicare patients hospitalized in 2013. It showed that when patients were cared for by their own outpatient physician they had a slightly better outcome than when the patients were attended to by full-time hospital based specialists who had not previously known them.

As an internal medicine physician who maintains hospital privileges, as well as caring for patients in an office setting, this study supports the type of medicine I have been trying to practice for the last 38 years. However, I am not naïve enough to believe it entirely.

In recent months similar studies have touted the benefit of female physicians over their male counterparts, younger physicians over older physicians and even foreign trained physicians over those trained in the USA. Based on these studies, one might conclude you should be treated by a young female outpatient physician who trained in a foreign country. While the JAMA study shows the success of the outpatient primary care physician, those in hospitalist medicine could similarly produce their own studies showing the benefit of using a hospital based physician or hospitalist.

I do believe having a familiar physician, you know and trust, adds a major level of comfort when you are ill. Having that physician consult within his or her referral network of physicians who know how that doctor expects the communication between doctors, and care to occur, is an additional benefit.

The fact that your personal physician knows what you look like in health gives them a distinct advantage in recognizing when you are ill. They know you and all about you and that helps. It especially helps patients with complex medical issues who require more time and thought. Being able to review the old records and previous specialty consultations which you were a part of seems to impart an advantage that someone just joining the care team does not yet possess.

This study does not say that outpatient primary care docs are better than hospitalists. It only points out that in a senior citizen population in 2013, patients cared for by their own primary care doctor had a better 30 day survival after a hospital stay.

The Turnovers are the Difference- Medical “Handoffs” Are Continually Fumbled

This is a humbling football season for those of us who root for Florida teams at the collegiate or professional level. It seems that each week after another loss we are listening to the head coach standing at the podium during a post-loss press conference talking about how if the handoffs had not been fumbled, and the ball dropped and lost, his team could have prevailed. It is hard enough to deal with the turnovers and fumbles when rooting for your team. It is far more difficult to deal with it when we are talking about human beings hospitalized and cared for by hospital employed physicians and then turned back to the community without communicating adequately, or at all, with the care team responsible for their continued care at the community level.

Take the case of GH, an 82 year old obese diabetic with high blood pressure, high cholesterol and heart irregularities requiring the use of Coumadin to prevent a stroke. He awoke one morning two weeks after a major auto fender bender and found his underwear stained in bright red and dark brown blood. His wife was unsure if it was coming from his rectum or penis so she called 911 and allowed the patient to be taken to the nearest emergency department.  He was seen by the emergency room staff and admitted to their contracted hospitalist service for presumed intestinal bleeding due to Coumadin toxicity.

Eight days later he was discharged home with an indwelling Foley catheter needed because of the “clots” in his bladder. His Coumadin had been stopped on admission and never restarted. GH could not get out of the bed and walk while in the hospital and he stubbornly refused to go to a nursing rehabilitation center as an interim step until he was strong enough to walk independently.  His frail 80 year old wife, battling a lymphoma herself, was given the task of caring for this obstinate man at home and emptying and caring for his indwelling urinary catheter.

On his first day back home, I received a phone call from his wife informing me of this. She didn’t know what she could possibly do to care for him because he weighed 230 lbs and he couldn’t get out of bed and walk. A nursing service and physical therapist had been requested but had not yet called to schedule a visit.  She was particularly disturbed because 12 hours had gone by since he got home with no urine appearing in the bladder drainage catheter. At the same time his lower abdomen was growing in size and he was feeling pain and discomfort at that spot.  Once again, 911 was called and he was taken back to the same emergency department. Paramedics transport sick patients to the geographically closest facility not necessarily the one his physician sees patients at.

GH was readmitted because his catheter was blocked with clots and needed irrigation and there were concerns about a urine infection. I spoke with the wife and children and asked for the name of his doctor but they could not remember it. They did remember the name of his consulting urologist. I called the urologist who was a bit put out to discuss the case with me. He told me that “our“ patient was bleeding from the urinary tract due to a transitional cell cancer of the bladder that he discovered and treated during a cystoscopy. He felt the prognosis was excellent.

The urologist declined to discuss whether the patient was additionally bleeding from his intestinal tract or if the appropriate evaluation had been done. He suggested I find the hospitalist responsible for the patient’s care. When I asked for the name of the hospitalist he told me he had no idea who it was. “They all look the same to me,” was his actual response.

I asked the patient’s wife to have her husband sign an authorization to release medical records and obtain the medical records of his admissions for my review. She did that and presented it to the medical records department who sent me a brief summary of his second admission. It took three phone calls to obtain the records of the first admission and another to get the emergency department records.  I needed this material because it was quite easy to convince the patient to come to a local rehab facility after this hospitalization with me as his attending physician.  The patient and family had no idea why he was bleeding other than “I had clots” in the bladder. They didn’t know the name of his hospitalist either.  When I received the records it identified the physician. I called the hospital to page her but was told she was “off “for the next few days. Her colleagues on duty did not know or remember the patient.

The patient records finally arrived. His admission diagnosis was bleeding due to Coumadin toxicity, but the INR (a measure of how effective the Coumadin is in thinning the blood) was very low indicating that his blood was not anticoagulated much at all.  An INR of 1.4 doesn’t cause bleeding and is not toxic. The medical record said he had hematochezia (blood in his stool) but there was no documentation that anyone had performed a rectal exam or examined a stool specimen for the presence of gross or microscopic blood.

There was a lab order to type and cross-match the patient for a blood transfusion but certainly no mention that a transfusion had actually occurred. There was a thorough procedure note from a gastroenterologist who looked in his stomach and colon several days after admission and found no source of bleeding. I called the gastroenterologist on the day I received the records but he was gone for the Thanksgiving weekend.  The records indicated the patient’s blood count showed hemoglobin of 9.3 on the day prior to discharge and 8.3 on the day of discharge but there was no mention of an investigation of why the blood count dropped and why he was released with a dropping blood count.  A chest x-ray report on his first admission showed a right lower lung infiltrate but there was no follow-up performed or reported.

The patient arrived at the local rehab facility on Thanksgiving morning. I saw him and performed a thorough history, review of his records and an exam.  He was no longer bleeding, with no black stools noted on my rectal exam and no microscopic blood on the stool occult blood slide test I performed at the bedside. His Foley catheter was draining clear non bloody urine and the patient looked pale but well.

It was really very easy to convince this patient to come to rehab to learn to walk again once I became aware of his hospitalization and condition.  After my initial exam I sat down with the charge nurse and we constructed a care plan for the next few weeks at the rehab facility and explained it to the patient. Then I told the patient he had bladder cancer with a good prognosis. He was completely unaware of that diagnosis until we had the conversation.  I called his wife and children separately and reviewed the diagnoses and care plans for follow-up.

GH entered the hospital on an emergency basis as an unknown. He was appropriately taken to the nearest receiving facility by the paramedics when he was found to be on a blood thinner and bleeding actively.  His inpatient hospital employed physicians prevented a catastrophe and did what was necessary to make sure one was not ongoing. They did little or nothing to insure the loose ends of his medical problems resulting in hospital admission were addressed or understood by the patient and family.  Little or no effort was made to insure continuity of care and appropriate follow-up.

Judging by the editorials in our peer reviewed medical journals, this has become the norm not the exception in our insurance company / employer driven health care system. The devil is in the details. Unless the loose ends are planned for , understood and addressed, patients like this will continue to be bounced back to the hospital as an “emergency”, unnecessarily spending money we do not have and do not need to waste.

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.