Sunday, April 6, 2014

Hospital Medicine Threatens Quality of Care with Communication Lapses

To those brave souls who have returned after digesting last week’s cheerleading on hospitalists, here is the Achilles’s heel of the system.  While the advantages are clear and substantial, there are serious vulnerabilities which have not yet been adequately remedied. 

Achilles Held by the Heel Being Dipped into the River Styx
  • Hospitalists cannot appreciate the medical nuances, personality, family dynamics, life events and prior experiences that may be well known by the out-patient physician.   
  • There are serious communication lapses, all of which cannot be bridged.  The out-patient doc may know that the patient’s chest pain is his typical anxiety and that it is not necessary to repeat the cardiac evaluation that was done 2 years ago.  The hospitalist may take a different tack here. 
  • Despite their best efforts, hospitalists know that they will not be seeing the patients after discharge.  As they are not permanently vested,  they may not address certain patient concerns, punting these  to the outpatient arena.  While this may be medically acceptable, it may be frustrating for some patients.
  • The hand off back to the out-patient doc after hospital discharge can be a minefield.   Patients may be on new medications.   They may have had a variety of laboratory and radiology tests.  Some of these results might be ‘pending’ at the time of discharge.   How does the out-patient physician reliably receive these results and understand their context?   Did medical specialists on the case leave recommendations that the primary physician now has to track and implement?   When the primary care doctor resumes care of a patient who had a complex hospitalization, is he now responsible to search out and address every loose end contained within the voluminous hospital record?   Could a single laboratory abnormality buried in the record that was totally unrelated to the medical illness become a medico-legal issue years later?  Do we really think that the hospitalists discharge summary to the primary care physician is airtight? 
A primary care physician recently complained to me that the local hospitalists never call him when his patient is admitted when he might provide useful information about his patient that only he know.   This is a legitimate gripe.

No system is perfect
So, over the past 2 weeks you have been offered a fair and balanced presentation on hospital medicine.   Which side of the issue has the better argument?


  1. For many years now I have felt that every hospitalized patient should have a constantly-attending advocate who is medically knowledgeable. At least one family member should be able to interpret, intercede, advise, and have full power of attorney for the patient. That person must sleep in, go with, and hang out with the patient 24/7. They must be logical thinkers who don't become emotional. They must be prepared to argue like a lawyer, have the memory of computer, the strength of Atlas, the stamina of a long distance swimmer, and the countenance of a pit bull. Hospitalists, especially those who don't speak English well, are often a miserable lot and patients are often bullied, over-treated, under-counseled, not understood, and even sometimes neglected. Docs in private practice sometimes depend on the hospitalist too much and tend the patient too little, but I think that's rare. Patients are usually frightened, cowering creatures who tend to regress in age when confronted with the giant internal MEDICAL MONSTER whose name is, "NoKnowledgeAboutThisSubject" and/or "ThisScaresTheBejeebersOutofMe,and their normally intelligent brains have left the building when it comes to making the right decision for themselves. Have pity! Hospitalists have shoved good nurses off onto the sidelines because there aren't enough nurses who are well-enough trained to be able to advocate for their patients, and their patient loads are way too large. As a patient, I've spent more time with housekeeping than a nurse, and I tend to want a weapon or a teddy bear when the hospitalist comes in, and I always need an interpreter because I don't understand foreigners well. I personally tend to fire them and tell them to get out of my room. Unless I need something that only they can provide, of course. The nice thing is, I have my real doc on speed dial. And I have the internet. :-]

  2. Barbara, your comment is scarily close to what I experienced advocating for my wife during multiple hospitalizations last year. The major difference was that nursing was good. The contract hospitalists were a danger. At least one seemed borderline mentally ill to me. The other hospital chain in town has nurses more like you describe, which is why we don't go there.