Requiring doctors to give orders on patients they have not seen

To meet Federal patient satisfaction goals, our hospital administration is requiring community based physicians to give patient admission orders before we have a chance to see the patient. Patients who self-refer themselves to the emergency department, are evaluated by the emergency room staff, and who are determined to require admission must be admitted by their community physician within 20 minutes of receiving a call from the ER staff advising the patient requires admission. In most cases, the community physicians have no idea the patient is actually at the ER until they receive that call.

It is bad medicine to issue patient orders on a patient you have not seen, taken a history from or performed an examination on. To complicate matters, the hospital does not require physicians to actually come in and see the patient for 12 hours after admission.   Think about it, diagnostic and care orders are being given routinely by doctors who have not examined the patient. The doctors then have the latitude to not show up for half a day to actually do an onsite evaluation.

One of the cardinal rules of medical training is you should do a thorough history and exam before constructing a theory of the causes of an illness and instituting diagnostic and therapeutic measures. The local hospital rule is a direct effort of the hospital to control all aspects of patient care for financial gain. They are buying up practices, revamping medical staff bylaws by manipulating the rules and, filling the decision making committees and legislative physician groups with salaried doctors they control.

Hospitals perceive community based physicians who are advocates for their patients as a threat to their financial planning.  The goal is to drive out the community based physicians because they act as a check and balance to the designs of the hospital system working as advocates of their patients. Do not believe for one moment that the goals and aspirations of patients in a community setting are aligned with the goals and aspirations of hospital administration.

I recommend that citizens look into the politics of their local hospital system.  If you do not, you may find that your doctor can no longer take care of you when you are sickest and in need of those professional services provided by someone who knows you well. You may find that you are transported from the ER to the floor quickly but you may not get to see a doctor for half a day.

How should this policy be altered to make sense?  Staff physicians should have 90 minutes to arrive at the ER and assume the care of their patients. In critical life threatening situations requiring immediate intervention, hospital ER staff should be providing stabilizing care until the patient’s care team arrives.

Requiring doctors to give orders on patients they have not seen is bad medicine. Giving those same doctors 12 hours to show up is irresponsible.

Steven Reznick is an internal medicine physician and can be reached at Boca Raton Concierge Doctor.

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  • Anonymous

    A hospital too cheap to hire a hospitalist group?

  • John Henry

    A hospital forcing the patient to use a hospitalist group, more likely. The next step is “incident reports” to document failure of an attending to report to the ED in time to meet their arbitrary deadline (20 minutes, I bet the patient waits a lot longer to see the ED physician.) With this “quality indicator” at stake, the proposal will be to admit all ED patients to the hospitalist group.QED

    • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

      I believe you are correct in your assessment

      • Anonymous

        Any way to take your admissions to another hospital?

        • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

          Yes that is a possibility except when the patients are already in that ER and have self referred themselves to that institution

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    I don’t understand. What happens if the primary care on record is employed by the hospital in one of those newly acquired practices? Do they also have 20 minutes to admit, or does the hospital automatically admit them under hospitalist care?
    Assuming they want to move folks out of the ER faster, and assuming there is some merit to this, and assuming this is not an emergency, is there no way to admit the patients, make them comfortable, and have them wait for their physician on the floor?

    • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

      You have twenty minutes to give orders period.  These are no longer verbal orders but are computer entry orders. The first order is they wish to have the admitting physician cede away their right to decide if this is an inpatient admission or outpatient observation by agreeing to let the case manager make the decision per ” Interqual” criteria.CMS regulations in the Federal Registrar cede this responsibility to the attending physician.  The second decision is to institute VTE prophylaxis ( you should see the recent article on this  topic suggesting there are more major bleeding episodes precipitated with this practice than life saving prevention of pulmonary emboli) . The hospital does have a slew of primary care practices they purchased. It is unclear whether these practices turn inpatient care over to the hospitalist service or still care for their patients themselves. 

  • http://www.facebook.com/people/Myles-Riner/100000936260954 Myles Riner

    There is a pretty reasonable solution to this problem that allows for some flexibility to ensure that the admitting physician sees the admitted patient in a timely way, immediately when indicated, a few hours later if it is not really necessary to disrupt the admitting physician’s office practice.  When the admitting physician is contacted by the emergency physician to arrange for the patient’s admission, they can discuss the orders needed to initiate the patient’s inpatient care, using a pre-printed holding order template to facilitate the development of these ‘initial holding orders’ to meet the specific needs of the patient.  The holding orders would have a specified expiration time, which can be negotiated between the admitting and ED physician, and there can be a clear statement in the hospital medical staff bylaws that gives the ED physician a clear mandate to determine this expiration time, or to insist on the immediate (within 30 min) presence of the admitting physician without concern for ‘blowback’ by the attending. 

    There is no evidence that such holding orders written by the ED physician in concert with the admitting physician increases malpractice liability:  in fact, it is probably safer (for the patient and thus for all the physicians involved) than allowing the admitting physician to ‘call in’ orders on a patient he or she hasn’t evaluated yet, it moves patients out of the ED into an inpatient bed quicker, if initiates treatment faster, and it improves communication between ED physician and admitting staff.  ED physicians sometimes balk at this approach until they have been doing it awhile, and then most come to appreciate the benefits to their own practice that accrue. 
    FickleFinger (www.ficklefinger.net/blog/)

  • http://www.bryantsstatisticalconsulting.com Donald Tex Bryant

    Has anyone at the hospital determined that 20 minutes is the optimal time to assure patient satisfaction.  Seems like some arbitrary rule by a bureaucrat to me.

  • Anonymous

    So, in your practice, if you have a patient admitted to the hospital at 2a.m. with something relatively stable (e.g., pneumonia, chest pain without EKG changes, etc) and with whom you are familiar, do you get out of bed to evaluate the patient within 90 min, drive to the hospital, evaluate the patient, put in orders, then drive home and go back to bed?  Do you leave your patients in morning clinic waiting while you see someone who just got admitted?  I certainly did not.

    I can see some of your arguments, but when I was in private practice I would get a report from the ER doctor and then give basic admitting orders to the nurse over the phone before I evaluated the patient and then see them for a full assessment and come up with a follow-up plan within 12h.  For unstable people, I’d make every effort to get there sooner or ask one of the hospitalists to see the patient and start things until I could get there. I would often disagree with the ER doctor’s assessment, but that is one of the drawbacks of community docs admitting their own patients to the hospital.  I agree that many hospitals are being very aggressive about making the lives of community docs more miserable, but your plan to have the staff physician evaluate the patient within 90min seems a surefire way to give the hospital what they want – employed hospitalists they can control to take over your admissions.

    • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

      In my practice if a patient is sick enough to go to the ER at night and be admitted they are sick enough to be seen by me or my associate that night. We get out of bed, get dressed and go in and assess and admit the patient . We both reside within ten minutes of the hospital. We often disagree with the ER doctors assessment and find because of their volume and time constraints their evaluation are often spotty and inaccurate. They recognize that the patient is sick enough to stay so we go in and see them. If a patient gets acutely ill during the day we reschedule patients and go in within 1/2 hour and evaluate them and admit them. We treat adults with multisystem disease. There are very few instances where they are sick enough to require emergent admission and can be called  stable unless you do the assessment yourself. We tell our patients who are delayed in the office or rescheduled that if it was them or their loved ones they would get the same attention
      I believe good internists and family practitioners who provide longitudinal care to their patients in the outpatient and inpatient setting bring a degree of comfort and aid to their patient in a time of crisis that makes their care superior to the hospitalist care. I did not say that you can quantify it as better or more cost efficient although advocates on both sides of the issues have plenty of data for their point of view, but collectively and emotionally better for the patient and their loved ones. I believe hospitalist medicine was created by insurers and hospital administrators as another way to control inpatient care and costs. It is the biggest conflict of interest existing in medicine today and Stark Laws have not addressed this issue. I believe young doctors enjoy hospitalist medicine because when your shift if over you are free, there are no major startup or overhead costs and hospital systems can set up a compensation and benefit package that rivals anything a new physician can earn in primary care as a startup. I believe it is part of the death plan for general medicine designed by academic nonpracticing physicians , hospital administrators and insurers. They do not like private physicians who are advocates for their patients and nothing else!

      • Anonymous

        Well said.

        “Private physicians who are advocates for their patients” are obstacles in the way of developing the assembly-line medicine that “academic nonpracticing physicians, hospital administrators and insurers” are hell-bent on forcing on all of us. 

      • Anonymous

        Thanks for the clarification.  I attempted to provide this level of care to my patients, but very quickly realized that I was doing so at the expense of my personal mental and physical health.  I admire very much physicians who can do this and not go crazy.  I agree with your disdain for hospitalists.  I struggled with the impersonal and aggressive care provided by the hospitalists in my previous institution, which was part of the reason I left rather than just surrender admitting privileges.  Now I do outpatient care and social rounds at an academic institution.  

        I wonder, what is your average inpatient census?  And how does your family cope with the knowledge that you cannot ever be fully present with them because you might need to be in the hospital within 30min at any time?

        • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

          For 26 of my 32 years practicing I ran a traditional IM practice and cross covered with an associate. We were off every other weekend. When you were on call you were expected to be available and our plans were made accordingly. I made all my children’s events and family events and did my share of parenting.  In the last few years I have limited my practice size but increased my availability. 

  • http://johnkhall.com/ John K Hall, MD, JD, MBA, CPE

    You noted that your hospital is seeking to meet federally defined patient satisfaction measures. What’s wrong with that? Your hospital is judged on meeting those measures. Federal funding may depend on that. 

    It’s frankly misleading to say that your hospital is in any way mandating when you see your patient or the timing of the orders relative to that visit. Make no mistake, YOU, the physician, make that decision. Your hospital, under Florida law, may not force you to write orders without seeing the patient as your title suggests.

    Your assessment of hospital financial status is partially correct. Every hospital is facing increasing financial pressure. No hospital can afford to leave money “on the table.” But why should a hospital allow any physician to jeopardize financing? As long as the requirement is applied uniformly a hospital is free to implement virtually any rule or regulation. As a physician with privileges at  (presumably) TJC accredited hospital you have some representation on the hospital’s governing body. 

    I seriously doubt that hospitals have meaningful fear of caring physicians regardless of the physician’s allegiances. However, diligent, caring physician’s would do as you indicate you currently do- you go see patients. Physician’s who do not wish to get out of bed can enter the orders on line. Physicians who wish to do neither can work elsewhere.

    There are no hospitals where politics- institutional, local, regional, and national play no role. Involving patients in these issues invites lay persona who are less informed than physicians. Certainly patients should “check out” their hospital. But they should in fact check to assure that the hospital meets the Interqual standards. They should check to see how ofter the hospital denies or revokes privileges. They should check out free information from CMS. 

    The standards developed are occasionally cryptic, unclear, or even stupid. But they are the best yardstick available and patients need some objective measure otherwise they’re left with judging hotel services.

    If these requirements are genuinely onerous then quit. Surrender your privileges and practice out of another hospital. If all the physicians feel the same way take the steps to change them. Your suggestions are reasonable and appropriate. But there is no chance that publishing them as a rant on a website will get them instituted.

    • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

      The Florida Medical Association and its legal staff have been looking for ways to remedy the coup pulled off by hospital administrations in sacking the medical staffs bylaws and powers in many community hospitals in the state of Florida . It did not occur without the members of the medical staff turning a blind eye towards hospital politics and then awakening one day with no leverage or ability to advocate for the patient. This is a process of at least a decade in the making. It starts by telling your medical staff that JCAHO no longer requires frequent meetings of the medical staff. These monthly  mandatory meetings at which your annual attendance was required a minimum of 50% of the time also had a voting quorom rule of 75% of the departmental members.  Once you eliminate meetings no one attends. You next propose that the quorom be reduced to a simple majority attending that meeting. You sneak that one by and suddenly you control it all . Now you change the bylaws to allow hospital paid physicians to have voting rights on the medical executive committee and medical staff, a process previously forbidden for fear of conflict of interests. The next thing you know your committees are restructured to just a few all chaired by physicians under contract to the hospital. Your nominating committees then carefully chooses non contracted physician leaders who are easily swayed. You eventually end up with a medical staff executive committee disproportionately represented by contracted physicians. That is how a medical staff passes a twenty minute rule to give telephone orders on patients you have not seen while allowing the staff to not show up for twelve hours in most instances.
      As a practicing community physician you take your patients to the best facility that is geographically closest to your office and practice base and that offers the best services and consultative and nursing care for your patients. You work within the system to improve the situation but take advantage of forums such as KevinMD to discuss it with your colleagues and the public. I hardly consider that a ” rant”

      • http://johnkhall.com/ John K Hall, MD, JD, MBA, CPE

        It remains frankly dishonest to make claims that you have “no leverage or ability to advocate for the patient.” There is nothing unsafe in the hospital’s requirements. There is nothing anti-patient. There is nothing intrinsically anti-physician. You’ve mentioned nothing that indicates that the hospital is violating any law or breaching its fiduciary duty to patients. The hospital owes physicians virtually nothing- remember physicians have clinical privileges not rights. You are using the veil of “patient care” to paint a villainous picture of the hospital simply because you don’t like legitimate, federally mandated, fiscally responsible hospital policy.

        Such changes happen at hospitals all the time throughout the US. It happens because physicians don’t show up for meetings. They don’t participate. They don’t read the minutes then follow through using established hospital procedures. Such physicians didn’t lose control they gave it away.  Every physician who didn’t vote, didn’t attend meetings, and didn’t follow up specifically chose to be somewhere else or to do something else rather than participate in hospital governance. TJC and hospital’s across the US reduced mandatory meetings at the request of physicians.  

        There is something you can still do. Change hospitals. If the hospital did something illegal then file suit- plenty of hungry Florida attorneys would love to take down a for-profit hospital for illegal activity. If it is in fact the best hospital in your geographic area then abide by the rules. Physicians always have a choice. Physicians live where they do and choose their practice constraints every day. If physicians don’t like a hospital’s practices then they should change the practices or leave.

        Each of us, I include myself as a practicing physician, must reassess daily our commitment to patient care and be able to effectively place our fiduciary duties into context within our lives. If we chose to place something, anything, above the privileges we have then we will find them eroded.

        Yes, whining in a public venue about the anxiety you feel because you wish the world would meet your perceived needs is a rant. A blog post- even a “hospital spring facebook revolution” will not change hospital behavior unless there is clear cut patient-centric issues.  This has nothing to do with patients and everything to do with the progressive loss professional prestige physicians have brought upon themselves.

        • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

          Nobody said that the hospital did anything illegal. Yes, physician lack of attention to hospital governance and politics did allow control of the medical staff bylaws to be changed right under their noses. This occurred during a period of tumultuous change for  physicians who actually took care of patients,  with insurers creating patient and physician panels and selling patients back to physicians for a discounted fee. Most physicians in my community who had established a business model and budget were scrambling to stay afloat and deliver available and accessible patient care. In a previous post, Dr Miranda Huffman discusses the time constraints and life style issues involved in getting up in the middle of the night to see a sick patient versus coming in hours later.  We all made those time family priority decisions. I put family and patient care at the top of my list. While I sat on the governing board of a new hospital locally and sat on the executive committee of a newly created 44 physician multispecialty group without walls, I gave up golf with the guys, boating and hospital governance to have the time to practice good medicine and be an attentive and caring father and husband. I regret not having the time to devote to the hospital and now that my children are older and out in the world ,  I may reinvolve myself myself in hosptial issues but think my time is probably far better spent teaching medical students and donating my time to patients without access to care. 

  • http://www.HealthcareMarketingCOE.com/ Simon Sikorski MD

    Very informative post. Thanks Steven!