“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.