The Ins and Outs of Primary Care

I realized I might as well post this piece here that came out this week my Department's "Thursday Morning Memo," a weekly email containing brief, reflective writings about our roles and experiences in primary care.  It's just a reflection from a couple of recent experiences on some of the things we are losing as primary care moves more and more toward complete separation of outpatient and inpatient care.

As this was written for folks in my Department, there are some local references that might not make sense to someone outside the Department reading it.

            Like many primary care physicians, I have mixed feelings about the evolution of my role in inpatient care.  I like taking care of acutely ill patients and (usually) seeing them get better.  I like (well, liked) being there for my patients, bringing my knowledge of them developed over time as an outpatient to their inpatient care and, hopefully, avoiding mistakes and duplicated effort that new providers might make.  Of course, like most of us, I don’t like the extra time demands of going to see hospitalized patients – and it seems particularly painful if I have no official role in their inpatient care.  Clinical systems don’t like those time demands, either, if they come out of scheduled clinic time; more and more, inpatient care is firmly walled off from outpatient care, connected at best by a discharge summary sent to the PCP and very rarely with any attempt to communicate when a patient is admitted.

            In different practice locations, I have participated in various inpatient call schemes, including every 3^rd night coverage for the practice, taking a week at a time, and no inpatient call – but not being on call for all my patients (nearly) all the time, so I cannot claim to occupy the moral high ground on continuity.  Mark Doescher and I published an editorial in the early days of the hospitalist movement, pointing out that there was no good evidence for better outcomes and there were potential significant downsides from loss of continuity.  But forces other than maximizing patient outcomes have driven the movement toward hospitalist care as the default in more and more settings, while the evidence for quality benefits continues to be rather modest.

            Recently, I had 2 seriously ill patients hospitalized at University Hospital.  I was not, of course, contacted when they were hospitalized, though I did receive notification when one was transferred to the ICU because of a relatively new policy in the ICU to contact PCPs when their patients are admitted.  Since I have an office in the Benedict Building in addition to seeing patients at the FHCW, it is relatively easy for me to visit my patients at University Hospital, unlike Memorial, which requires making a trip just for the purpose.

            Both patients primarily spoke languages other than English, which can present a barrier.  The floor admission note when one patient was transferred out of the ICU noted that she spoke broken English and her native language and a limited interview was conducted in English as “no interpreter was available.”  To my relief, when I went to see her, the speakerphone on a pole (product of a past project in our Department) was right next to her bed, so clearly someone knew about using that, even if not the admitting resident.  Other times I visited her, it took up to 5 minutes to find the speakerphone so I could contact a telephonic interpreter.  I spent my time just asking what questions she and her family had and doing my best to answer them, in the absence of any communication from the inpatient team beyond what I could glean from their notes and her labs.  A couple of times, I hunted up her nurse to see if they could ask to covering inpatient provider to write some orders to make her more comfortable.  My patient asked if I could, please, come see her every day.  I said I would come frequently, but probably it wouldn’t be every day.  It certainly seemed that nobody else was taking the time just to sit and answer questions with an interpreter.

            My second patient sustained a stroke and initially had complete expressive and dense receptive aphasia.  Her recently-immigrated family spoke little or no English but, luckily, I speak one of their languages reasonably well and I had met several of them previously so they knew who I was.  They had many questions – many of them unanswerable, like why this had happened and what was going to happen to her.  They asked when I could come back and see her again.  The day she was being transferred to a rehabilitation facility, I came by and found she had made remarkable progress from my previous visit a few days earlier, with good comprehension and the ability to express brief sentences with only moderate dysfluency.  The family members clustered around her immediately asked me to talk with her about her discharge plans, as she was saying she wanted to go home and did not understand why she should go somewhere else.  After I reviewed the rationale and potential benefits of intensive rehabilitation prior to going home, she agreed to the plans for a discharge to rehab.

            In these cases, my visits were purely social.  They were not billable (or at least not billed) and came out of my “free time.”  I am no saint – I did not see these patients every day, nor do I do this very often for patients hospitalized at Memorial given the added barrier of needing to make a special trip there.  But having two hospitalized patients at the same time and seeing how much my visits apparently meant to them and their families has made me reflect on the perhaps Faustian bargain we have made to separate outpatient and inpatient care in the name of greater efficiency (our Department and clinics love the increased clinic sessions and scheduling predictability, and evidence suggests modest decreases in inpatient costs and length of stay with hospitalist care).  It certainly doesn’t feel patient-centered.  Perhaps, as we move to Accountable Care Organizations, we could reconsider this path, since payment should not depend simply on visit volume, but I suspect no metrics, even patient satisfaction, would capture the benefits of maintaining this human connection in a way that could change the calculus of this choice.  Absent a metric and a push to improve it, are we and our patients losing an important component of the patient-provider relationship?