“Thank you for calling, please hold…” by Pat Conrad MD
Internist Stephen Schimpff, MD is concerned about physician-physician, hospital-PCP communication. Writing in Medical Economics, he begins with a case study of an elderly demented female nursing home patient who had mental status changes and was rushed to the hospital. Of course she got the full ER “G” panel, and was admitted for a UTI. Before it was all over she had gotten the executive platinum panel, including cardiology and neurology consultations, and of course an echo and MRI. In what reads to me as sanctimonious editorializing, Schimpff writes, “She was ultimately sent back to her facility after tens of thousands of dollars of medical care, worse off than when she arrived. She was fortunate to have not suffered further harm from her hospital-induced delirium and the potent medicines she received.” Uh-huh.
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The author uses this case to point out how better hospitalist-PCP communications would have kept this patient in the nursing home on antibiotics, which would certainly have been cheaper, and presumably better for her. He may well be right in these assertions, but we don’t know a couple of things.
Was the demented patient a full-code, and/or was the family demanding that “everything” be done? Was the hospital leaning on the staff to admit her? Schimpff scolds the ER doc and hospitalist for not contacting the patient’s PCP. It is extremely likely that the ER doc was too busy to wait on a call to the PCP when there is a definite lag time for labs and head CT, and the waiting room is full. It’s more reasonable to think the hospitalist might call the PCP, but I hear their days get pretty full too.
Schimpff says, “Hospitalists often state that they just don’t have time to call the PCP, but when they do, the PCP is not available. Each is culpable. Each must remember that the issue at hand is the patient’s care and welfare, not their convenience or preferences. It is a matter of professional responsibility.” That is a nice statement from a former academic physician and university hospital CEO. He does admit that the rising workload and need to get a complete workup encourages multiple consultations, but it’s unfair that he does not also mention the huge expectations necessitated by defensive medicine. I don’t care how demented or contractured this poor lady was, we could bet there was a lawyer lurking at the door, just to make sure she got every test. And while Schimpff’s point about communication is itself true, it loses some validity in our modern context: even if the ER doc or hospitalist DID talk to the PCP, would they necessarily have done anything different? The PCP would likely back off and give the familiar response, “But hey, you’re the one seeing the patient.” I completely agree that we waste ridiculous, insane truckloads of cash in completely overblown workups, and I’m as guilty as anyone. But no amount of time that I don’t have spent chatting with the PCP is going to change what we do in the real world.
And here is Schimpff’s real kicker: “Not only can outcomes be improved, but costs can drop and patients and their families can feel more comfortable knowing that their own doctor is involved in their care. If necessary, hospitals should set policy that makes hospitalist to PCP communication mandatory; everyone will benefit.” Third party payers, state medical boards, malpractice lawyers, and societal expectations tell physicians that cost is no object, and pile more and more busy work onto an already busy day. Patient/family comfort should be the goal, but the hospitalist will have increasingly less control over the pressures that thwart it.
I remember when I was computerizing my clinic that the utopian ideal was, that this would broaden the communication between PCP and specialist, between hospital and clinic follow-up. The first electronic record was in the ER, and it suffered for years from repetitive phrases and default entries in such as review of systems which would tell you the patient didn’t suffer from dyspnea when the admitting diagnosis was respiratory failure and the history was “shortness of breath.” The next fail was that the hospitals told smaller practices that they were too small to bother with connecting to their network, as the business they brought in didn’t justify the effort, even with government agencies made responsible for seeing it got done. No teeth! Why should the hospital spend money? Great for the IT folk who were flogging the crap software and loads of hardware, who sold the government a bill of goods. Vaporware is legion. And fear of HIPPA keeps records from coming to the PCP with details unless a release is faxed, and you can wait for it to come back to you with the patient in the room. Even then, the display of useful information is scattered in the wind of verbiage and default statements meant to satisfy a bean counter’s criteria or by some regulation. It’s in there, somewhere, or often it actually isn’t in the record. The case dictation has no trail of medical thinking. You must infer. The blood pressure medication was changed because of why? Was in not on the hospital formulary? Was it contrary to aiding what was being treated and why? And can you figure it out in the 12 minutes your MBA at the mega-group practice demands you limit your visit to lasting, even if the patient is demented and the family has to work rather than be there to try and explain? Like the lack of useful owner’s manuals in the IT industry, it makes the specialist indispensable, if he never explains his magic spells to the apprentice or “lesser” practitioners. It’s job security. Hospitals now treat data (big data, don’t you know) as leverage. Their doctors get it, but outsiders? Why should they help them? You don’t find “helping your enemy” in Sun Tzu’s “The Art of War,” required reading in business schools. (https://www.forbes.com/sites/ericjackson/2014/05/23/sun-tzus-33-best-pieces-of-leadership-advice/#27bdad745e5e) Their bottom line is not to treat and benefit others, and they own you, or you don’t get the data. The Sisters of Mercy are gone from our local hospital, and that most caring hospital is now multi-national. What did you expect? So instead, let’s have meritocracy step in, and tell the doctor it’s their fault, so they don’t have to pay them like last year, and they pocket the difference. What do you think this is? Socialism? The real patient is the stock investor. Short term gain is King.
Great post.
The idea of “mandatory communication” is part of the problem. I often receive hospitalization reports, specifically labeled as being to meet a CMS requirement, which tell me my patient may have been seen or treated by one of their providers or in one of their facilities. I can usually figure out who the patient was if I look thru all about six pages of useless garbage, but it is truely impossible to determine who/where treated them how for what, even if I call medical records at the flagship facility of the group. But I do know that they were addressed by their gender of choice, and were judged to have not been a victim of domestic violence. Such a waste! A one paragraph statement by the provider would likely “communicate” much more effectively.
The example is extremely common and as the PCP trying to communicate with the rest of the system, I can say it is not a mere communication problem. The problem is no one knows enough geriatrics in the hospital system to avoid doing deleterious things. Even the author takes it on faith that it wasn’t asymptomatic bacteria. As long as geriatricians have no huge research budgets and no power in the education of other physicians and staff, no amount of communication can change it. As long as power and money comes from Pharma and Medtronic into our education system, we are doomed to be done in someday by the very systems that may possibly benefit some of the young, living a life of poverty followed by enough money spent on our last year of life/torture as could have given us a great retirement.
I disagree that fear of litigation is the problem. If geriatric malpractice litigation was lucrative this problem would have been fixed already, but people don’t lose money or someone to support them when the frail are injured. A geriatric minded PCP calling the hospital and specialists and telling them what good geriatric care entails or how what they’re doing might be harmful has no effect because no one, lawyers or educators, is forcing anyone to learn what is known.