Sunday, November 4, 2012
Hospitalists and the field of Hospital Medicine: why we are sometimes terrible and how we can be excellent
Hospitalists (the internists who practice hospital medicine) take care of patients who are admitted to hospitals when their own doctors do not. Primary care doctors are less and less often involved in taking care of hospitalized patients because they are so busy taking care of patients in their offices that taking the unscheduled time to go to a hospital as well has become impractical. When there is a doctor at the hospital to take care of a patient who comes in very ill, there is no delay in getting appropriate care and the primary care doctor doesn't have to cancel a waiting room full of patients in order to come in. Hospitalists get really good at taking care of the illnesses that are severe enough to lead to hospitalizations. Conversely, primary care doctors forget how to take care of these problems. Hospitalists are paid to be in the hospital at night, so it is no hardship to be at the bedside in the wee hours when people so often decompensate. Doctoring in the past was more often a profession that was not compatible with having good family time or enjoyable hobbies. Separating office work from hospital work makes it much easier to be a reliable spouse or friend.
On the other hand...The absolutely best care a person could get would be delivered by a competent physician who had known a patient for years, with appropriate input from other physicians depending on the patient's specific needs. As a primary care doctor, when my patients were admitted to the hospital, I knew what had happened that lead up to their illness, what we had tried before, how the person interacted with their family, what their values were. The patient also knew me, trusted me, and felt better in the hospital with its strange smells and routines just seeing my familiar face.
Hospitalists are shift workers, usually working 12-13 hour days, 7 days on, 7 days off, and they are randomly assigned patients as they come in to the hospital. They usually see 10-20 patients a day, discharging and admitting patients to the hospital and coordinating their care. They have access to the patient's computerized and sometimes paper charts, can call their primary care physicians for more information (if they can get them on the phone) and can often take a pretty good history from the actual patient. There is not a whole lot of time for all of this, though, and with up to 20 of more unfamiliar faces in a day, it is pretty difficult to have the kind of intimate knowledge of a patient that would lead to optimal care. Although most doctors are internally driven to do the right thing for every patient they see, it is more work to take a good history than to just go with what the emergency room doctor who originally saw the patient said, it is more work to discharge a patient than let them stay in the hospital one more unnecessary day, and generally just more work to do the job right. Because the hospitalist has to be efficient in order to get all of the tests ordered, evaluated, documented, patients admitted and discharged, consultations ordered and checked, crises averted or alleviated, they often don't ask the questions that would allow a patient NOT to have a test or procedure, they don't necessarily have the gentle conversation that allows a person to make a decision to forego end of life heroics, they don't have time to realize that the patient is really now well enough to go home if certain arrangements can be made. And since the patient doesn't really "belong" to the hospitalist, will not come back and see the hospitalist again, making a meaningful connection is harder, even though it is the right thing to do. Solving the mystery is still interesting, but not imperative, since chances are good that an unsolved mystery will only come back to haunt a different hospitalist.
And yet some hospitalists are excellent. And some hospitalist systems foster excellence.
I have worked in 5 different hospitals in the last year, in 5 very different hospitalist programs. What makes a good one seems pretty clear. First, although good systems are important, there is nothing that can take the place of good doctors. Some of the doctors I have worked with are outstanding. They are patient, have good senses of humor, work well with nurses and patients' families. They take time to really listen to patients. They love the challenge of severe illnesses and have creative minds. Bad systems, though, can burn out and chase off good doctors. The best programs have slightly smaller work loads than the worst programs. Seeing less than 15 patients in a day makes us much more likely to do a good job, to do that little bit extra that makes a difference, to read about what the experts say. When the patient transitions from one doctor to another, either day shift to night shift, or going away after a week of work, it is very important to actually talk to the doctor who will be taking over. Writing something doesn't cut it. The back and forth conversation, in which doctors ask each other what is really going on, suggest alternative diagnoses or testing not only is good for patients but counteracts the isolation that leads to burnout. Some small hospitals foster collegiality because doctors from all of the specialties end up at the same nurse's station and conversation happens. One program actually had a meeting of the hospitalists every morning which included nurses and other specialties and really improved communication and broadened perspectives.
All of the hospitals have had some sort of computer system for record keeping. A simple, user friendly computer system could free up so much time to spend at patients' bedsides or talking to their primary care doctors. Unfortunately, though each of these hospitals computer systems had some clever ideas, none were anywhere near what I would call simple and user friendly. If it was possible to cut and paste them together, the Vista, McKesson, Paragon, Meditech, Hero systems, it might be fabulous. The one thing that is common to all of these computerized medical record programs is that most of the people who use them hate them. Interesting.
So I guess it's easy to have an excellent hospitalist program. All you need is great doctors, a simple and user friendly EMR (electronic medical record), moderate work loads and face to face signouts. Since this recipe is difficult to concoct it's not too hard to see why hospital medicine is sometimes not excellent. I would like to blink my eyes and find out that we had gone back to the system in which patients were seen by their own doctors in hospitals but the trend right now is towards more hospitalists, not less.