by Edwin Leap, MD
An emergency physician, like me, may be the worst possible person to discuss relationships with patients. I mean, one of the reasons I chose this specialty was that I didn’t want long-term relationships with my patients. I see, now, that God has a great sense of humor.
See, the county I landed in after residency is small enough that I do know many of my patients, and I do see them more often than you might imagine. After all, our hospital is ‘the only game in town.’
There are some patients I know quite well, and thus I know with reasonable accuracy who is sick and who isn’t, based on how they looked or behaved before. It doesn’t always work, but frequently it does.
Which brings me to trends in primary care. I don’t know if I’m really a primary care provider or not. Some years we are, some years we’re considered specialists. Whatever. It doesn’t really change the work. It might change the pay, as administrations place different emphasis from time to time. But I do see a lot of primary care. I watch internists and pediatricians, family physicians and ob/gyns do their work. And what I see, from the standpoint of the emergency room, is a drift away from relationship.
The thing that brings it up most poignantly is the trend towards hospitalists. For those of you not acquainted, the hospitalist is a physician whose practice is focused on admitting patients to the hospital, caring for them, and discharging them back to their regular physicians (if they have one) when the acute situation is over.
Now, I know some great hospitalists. And I understand the need for them. As hospital care becomes more complex, as offices suffer when their docs are at the hospital, as the goal becomes ‘discharge as soon as possible,’ wherein utilization review committees are prime-movers, the idea of the hospitalists makes great sense, and probably bears much fruit.
However, a relationship is severed. We have many community physicians who do not do hospital work. And more now that the hospitalist option exists. So let’s say I have patient X in the evening or on the weekend. His physician doesn’t admit. I call the hospitalist. ‘Patient X is having chest pain. His cardiac labs and EKG look alright, but it just seems concerning to me. Can we admit him?’ Hospitalist: ‘well, he doesn’t have risk factors and everything looks OK, what are we going to do? Do a second set of labs and let him see his doc tomorrow.’
Now, that was a technically correct encounter. But if his own doc had been on call, as in the past, he might have said ‘I’ve known him for years. He doesn’t complain. That isn’t like him. Let’s keep him overnight.’ Scientific? Maybe not. Possibly useful? Absolutely.
See, the hospitalist is driven by admissions and discharges. And he or she has no abiding relationship with these patients. In the same way, the family physician who won’t admit has severed his relationship. ‘So, I see you were admitted last week!’ He’ll get a report. But the next serious illness that comes around will still be a situation in which the patient is admitted to a stranger with a lack of personal interest (I don’t mean that they don’t care, just that they aren’t personally connected over a long period of time).
I see both sides. The hospitalist has a focused mission and a busy service. The family doc has a focused mission and a struggling office to run. But somewhere in between is the patient, who has been left afloat between two continents. I guess the ER is the ‘desert island’ in between.
I don’t know the answer. But I know that when they come to my emergency department, I have to put together the pieces and do the right thing. I don’t have all of the information. But before you scream ‘EMR,’ remember that medicine is more than data points. Even if I have the data, I don’t have the sense of the patient. The knowledge his or her physician has from personal, repeated interaction.
So I have to put the data together, decide if it heralds something perilous, and then I have to be a salesman . . . just to get someone else to look at the patient. I am, in a sense, a voice-activated robotic surrogate for everyone; from family physician to hospitalist, obstetrician to urologist, ENT to general surgeon. But then, that’s another post altogether.
What I mean to say is, when we lose relationship, we lose some of the most important bits of information in all of medicine. Humans are complex, and in order for us to care for them, at least in the setting of being hospitalized or discharged, it’s remarkably useful to know them.
What do we do to fix it? I have no idea. I don’t believe it’s a thing that can be repaired with compensation schemes. Perhaps only philosophically, as we teach young physicians the value of relating to their patients more than scientifically. Or if it works better, to explain to them that science is more than labs, stress-tests, x-rays and biopsies. Science is the pursuit of knowledge.
And patients are best known by . . . knowing them.
How’s that for a koan?
Edwin Leap is an emergency physician who blogs at edwinleap.com.
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Related posts:
- Hospitalists assimilate inpatient medicine, is resistance futile?
- Is Medicare policy responsible for hospitalists?
- Should hospitalists control hospital beds?
- Hospitalists: The last true internal medicine physicians?
- Hospitalists are here to stay, or look how ER physicians are thriving
- Are hospitalists financially viable?
- Hospitalists and the importance of the patient-doctor interaction
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Hospitalistism is a fairly new arena. In my experience patients have become more accepting of being admitted to the hospitalist service now than before. They get immediate attention in case of emergency as the hospitalists are always in-house. Some of the repeat admissions do bond with the hospital doctors and know them by name. For Primary care docs it is a relief to have hospitalists. They do not have to rush from their busy clinic for an emergency anymore. They are able to spend time with their families insttead of arriving home late in the night. With in house physicians available, hospitals have been able to form Code Blue and Emergency response teams thus improving medical care to another level , especially in community hospitals.
Usually if the hospitalists recommend outpatient follow up rather than admission, I do get a call from the ER docs to make sure I agree with that. And yes if a patient has never complained before and is suddenly complaining of a”tolerable” abdominal pain, my clinical suspicion heightens, and I can express my concern to the ER doc and then he can relay it back to the hospitalist. Usually that solves the problem.
Dear BookMD, Your heart is in the right place, only the real grass roots fallout is missing. Accepting does not mean liking and no one asked the patients if this is what they wanted. It is also tough for patients to give an answer in opposition when they don’t feel so hot or are frightened.
Back to the office. Daughter Sally calls asking about her hospitalized Mom. She just got in from Osh Gosh and she is really worried about her mother.. You don’t have the information and will need to put her on hold. You hope the appraisal from the hospitalist meets your standards and you will not have to call back again. Without a doubt the patient-doctor chain has been broken.
As for better lifestyle arguments, if you get enough of these kind of phone calls it could put a damper on your day, especially with ramifications. Also adding more personnel to take care of the patient has just increased the cost. Hospitalists have overhead too. Your income will fall eventually because insurance will not pay the full freight for both.
For 30 years I was a solo physician making hospital rounds, house calls, and nursing home rounds. Yes sometimes it was a pain in the butt, but the gratefulness and professional pride I felt could not be substituted. Yes, I ate breakfast with my family, attended the kid’s functions, and went out on dates with my wife. The income for most of time was pretty good too. Choices, choices. If we make them and they are mostly correct, there will be precious little discussions like this one. To be more clear, picture yourself as the patient, and hearing the words as you are scared silly in a hospital, that Dr. X will be caring for you, instead of your family doctor with whom you invested so much trust. Remember some day you may have to be cared for under such a system and pay for it also.
The real question is outcomes. Are there differences in outcomes between hospitalist-treated pts and those seen in hospital by their PCPs? Is there a hospitalist out there to help with this question?
I’m afraid the train has left the station.
“The Moving Finger writes; and, having writ,
Moves on: nor all your Piety nor Wit
Shall lure it back to cancel half a Line,
Nor all your Tears wash out a Word of it…”
Omar Khayyam, “The Rubaiyat”
A great post. I work both in and outpatient, a mix of hospitalist and clinic with patients I have known for years.
The problem is relationship doesn’t mean much outside of context of the chronically ill. Relationship is why medicine is fun for me, but it certainly doesn’t count for much to malpractice attorneys, medicare payers and auditors, and angry family members who look often consider you third-string next to the specialists. Just go to CNN and read the posts from angry family members who have an ax to grind with their PCP whose relationship with their now sick parent seemingly counts for nothing.
Ive done it all – private practice – ED – hospitalist. Right now, I am now a hospitalist for a small rural hospital whose local Pediatricians threw up their hands and gave up their privileges. I don’t blame them. They could not do it all (especially in terms of the 24-7 call) and have any kind of life.
In all honesty, I see little difference between a hospital having in-house doctors and nurses or even hospital executives (of the three, only the doctors generate income). And I think that what hospital doctors make shouldn’t always be about what the doctor can bill, but what he/she does to keep the medical machine moving and stable.
The hospitalist “profession” exists now, in large part, because primary care providers were taken-for-granted and abused for years . . . by hospital administrators – who regarded them as “a dime a dozen” and treated them accordingly (even as they jacked their own salaries up) . . . by hospital/OR-based doctors (in Pediatrics that mean the OB’s and their pseudo-emergency C-Sections at all hours of the day and night – or ED doctors that were “uncomfortable” with children and turfed the entire work-up to the Ped) . . . and by patients themselves – who over the years honed their sense of entitlement, and the notion that “on-call” for emergencies means “beck-and-call”.
And let’s not leave out the lawyers – who hover like vultures over all of it – looking for the smallest mistake.
As things are done now, doctors (in whatever cog on the wheel) can set boundaries and limits. They can protect themselves and their private lives. It may or may not last.
Call me cynical, but right now, in medicine, people pretty much have what they asked for and deserve.
No one was really paying attention as it just happened.
isn’t the idea with obamacare is trying to prevent admissions that don’t follow clinical guidelines, so while I agree with using your gut to do things, this is not going to be allowed with obamacare.
I know this isn’t a discussion on health care reform but since someone is recommending a course of action you should make sure it’s at least going to possible in the future.
I don’t see the hang up on the doctor-patient relationship. While there is a disconnect when the patient is being cared for by a hospitalist, there is also a loss of relationship building when patients are handed off to mid-level providers.
While there may be value in a doctor-patient relationship, the current medical system makes such relationships very diffucult. When I developed a complicated condition, one that took years to diagnose, my PCP never had the time to see me during periods of acute illness. He never saw me when I was sick and all those important bits of information were lost. I suffered for quite some time before finding a specialist that was willing to care for me when things were bad, not just when I fit into the schedule.
In primary care, the doctor-patient relationship isn’t profitable.
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