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.
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 3rd 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?
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