Excessive turnover in inpatient care can wreak havoc

If you (or a loved one) have been admitted to a hospital recently, you were probably surprised by the number of times you were asked the same questions. At first you might assume that the staff are being diligent in double-checking your information, but after the fifth healthcare provider asks you to explain why you’re there, you start to feel as if interacting with “the system” is like talking to a person with no short term memory. It’s as if the hospital itself has some kind of dementia.

Recent adoption of electronic data collection, shift working, team management, and over-specialization have exponentially increased the complexity of patient care. Unfortunately, the complexity is fueling medical errors, repeat and unnecessary testing, as well as misdiagnoses. As primary care physicians have eloquently argued, being cared for by those who don’t know you can be a huge cost driver, and create all manner of unnecessary anxiety. Perhaps a true story will help to illustrate my point?

Not too long ago, I was caring for a patient in an acute rehab unit. Over a three week period of time I got to know her idiosyncrasies quite well. She had had a recent chest surgery and the surgical site was exquisitely tender, but without evidence of infection. In addition, she was allergic to certain kinds of tape and had had an unfortunate blistering reaction to the tape that had been near her surgical site. She had anxiety disorder that was well managed with medicine and talk therapy. She had a large family who visited her daily, some of whom had decided not to vaccinate their children. I had spent a good deal of time helping them to understand the risks associated with those choices.

I signed out my patient’s care to the weekend hospitalist team on Friday afternoon, and was alarmed to discover my patient in an isolation room on Monday morning, in the midst of a nervous breakdown, and surrounded by gowned family members who were furiously calling for emergency transport of distant children to various hospitals. I had not heard a peep from the hospitalists about events over the weekend, and immediately gowned up to find out what was going on.

My patient sobbed, “The doctor told me I have shingles. Now my grand children are going to get chicken pox and they’ll have brain damage!”

“Which doctor told you that you have shingles?” I asked.

“I don’t know his name. Some doctor who was here this weekend,” she wailed.

“How did he know you had shingles?” I said, sitting down next to her bed, trying to console her.

“He looked at my chest rash.” She replied, pointing to the patch of contact dermatitis at the site of the recent surgical tape removal. “He asked me if it was painful and I said ‘yes.’”

“But it’s the surgery site that’s painful as it has always been, right?” I said.

“Yes, it’s the same pain.”

It dawned on me that a linear patch of painful blisters did look a lot like shingles, especially to someone who had never seen the patient before. I could see why the hospitalist suspected it, but unfortunately he wasn’t aware of her long standing wound tenderness or tape reaction. The fallout from this well-meaning misdiagnosis was especially large, given the psycho-social context. A large, anxious family, with many unvaccinated kids who had traveled from far away to see grandma in the rehab unit over the weekend. It was the perfect storm.

Needless to say, it took me several days to unravel the damage, reassure the family, and recall the “emergency chicken pox” ER visits that were planned in distant parts of the state (where the kids made their home). The pregnant nurse who was treating the patient over the weekend had to create a full report to employee health about her “high risk encounter.” And in the end, the family and nursing staff didn’t feel completely certain that she didn’t have shingles, since it was officially documented in the EMR by at least one physician, no matter what my argument.

This is just one example of how cross-sectional relationships with patients (rather than the preferred, longitudinal kind), can wreak havoc. Because of the incredible degree of turnover inherent in today’s inpatient care systems, patients are examined “from scratch” by every new shift of nurse, physician, physical therapist, case manager, etc. There is very little context available to assist with interpreting how the patient is doing compared to their previous state. Searching for such pearls can be time consuming in a medical chart that is not designed for clear communication, but billing purposes.

What are we to do when faced with a new patient with a concerning complaint? Search the chart for historical clues, look for a staff member who has known them longer than one shift, or perhaps ask the patient: “So can you tell me again why you came to the hospital?”

Val Jones is founder and CEO, Better Health.

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  • Eric Strong

    “Recent adoption of electronic data collection, shift working, team management, and over-specialization have exponentially increased the complexity of patient care.”

    I think you may have things backwards. EMRs, shift working, team management, and increased specialization have evolved in order to meet the demand of ever increasing complexity of patient care – though they are obviously not always optimally implemented.

    “As primary care physicians have eloquently argued, being cared for by those who don’t know you can be a huge cost driver, and create all manner of unnecessary anxiety.”

    This makes it sound like you are arguing that PMDs should be caring for patients in the hospital rather than hospitalists. Whlie it is critical for there to be good communication between PMDs and hospitalists regarding their mutual patients, there are many benefits of hospitalist medicine. If you got admitted to the hospital with an MI, severe pneumonia, or a stroke, would you want to be treated by a physician who sees those problems a couple times a year or a couple times a week? I don’t care how well my PMD knows me, I would prefer she not be the one choosing my inotrope, picking my vent settings, or deciding whether or not I should get thrombolysis.

    And your example of being asked the same questions over and over again in the hospital has nothing to do with whether or not your PMD is directly involved in your care, since the ER triage nurse, ER doc, admitting floor nurse, respiratory therapists, medical students, and all of the consultants will still be asking the questions again and again regardless.

    • SteveCaley

      “And, in the recent regrettable issue with the Titanic we can all rest assured that all White Star Lines policies were followed carefully to the letter.”
      Why not go to one of the nicer third-world countries, one that has comparable outcomes with the US – there’s quite a few – and see how THEY run THEIR hospitals? Are they chock-full of a clown-car parade of specialists, insurer representatives, utility managers? How do THEY prevent their surgeons from cutting the wrong leg off? Isn’t this horror an example of our vanity and hubris, that somehow American healthcare is THE BEST?

  • SteveCaley

    “If you got admitted to the hospital with an MI, severe pneumonia, or a stroke, would you want to be treated by a physician who sees those problems a couple times a year or a couple times a week?”
    The presumption is that there is a Best Practices for disease treatment, and only those who have treated it within the last few days are truly competent to do so. Individual patients, on the other hand, are interchangeable; an in-depth and long-standing relationship are incidental to the hospital course.
    And yet, in most cases, it is the nature of the individual patient that contributes to the history; and so does the prodrome of the illness.
    The deathly ill – people on pressors and ECMO – benefit from those who know the hospital incidentals and machines more thoroughly than the patient. Are all the hospital instruments now so complex that they need professional Wizardry?
    Pneumonia with simple progress; or chronic pancreatitis that I’ve treated in-patient already several times – what is mystical about that?
    If one expands the “scope of practice” so DC’s and PA’s are PCP’s, then, of course – you need a hospitalist. Why is that better?
    As I prepare to ease out of American ‘medicine’ I expect to see the cost EXPLODE and the balkanization accelerate. Send Dad to Mexico and move mom to Canada will be the best choices ever.

    • Eric Strong

      “The presumption is that there is a Best Practices for disease treatment, and only those who have treated it within the last few days are truly competent to do so.”

      Uh, no. But the average hospitalist is more competent than the average PMD in treating the typical acute medical problem that is severe enough to warrant admission to the hospital. Just as the average PMD is more competent than the average hospitalist in managing chronic problems longitudinally.

      “Are all the hospital instruments now so complex that they need professional wizardry?”

      No, but many are. Assuming you are a PMD, if you needed to place a central line on an inpatient, would you break out the ultrasound and use it to perform the procedure yourself? Probably not. Instead, you would either perform the procedure blindly (not recommended), or more likely would call an anesthesiologist to place it for you (at substantially increased cost). Keeping up with newer antibiotics and local resistance patterns is very challenging if you aren’t treating complicated infections routinely. How do most PMDs do with reading ECGs? Do they rely on Dale Dubin to teach them everything they know, or do they call a cards consult for their ECG interpretations? A patient got a stat CXR? Well I guess that means waiting a few extra hours for the official read to come in, since CXR interpretation is a skill that requires constant practice to remain good at it. These things are not in a PMD’s typical area of expertise. While the chronic pancreatitis that you’ve treated “several times” may be a straight forward admission not requiring specific inpatient expertise, a patient with chronic pancreatitis would typically be the least sick patient on my inpatient census (excluding uninsured patients waiting for SNF placement).

      And this hasn’t even touched on the fact that hospitalists are in the hospital 24/7, and can come to the bedside immediately in the event of acute changes in status – situations in which it might take a PMD hours to come in from clinic in order to maintain continuity of care.

      • NPPCP

        Well spoken…..We NPs are on the exact same page!

      • JustADoc

        A good FP/IM actually does do those things on a regular basis that you act like we don’t do.
        Our hospitalist census is about 15-20. My groups census is similar. Any one hospitalist works 16 days/month and sees 1/2 the census(much less on nights, more on days) so about 80 or so patients a month in the hospital or 960/year.
        I had 700+ inpatient encounters last year in addition to 4100+ outpt encounters. The hospitalist consult rate is significantly higher than mine. Good enough for you?
        many FPs have allowed their skills to be downgraded by the healthcare industry. But out of residency they have the skills if they choose to use them.

      • SteveCaley

        Thank you for your entirely ungrounded and baseless presumptions about what I can and cannot do. I would be glad to offer my uninformed presumptions about your abilities and shortcomings, but courtesy forbids.
        Could I, in fact, be the PMD that is reading the EKG’s you send out for review?

        • Eric Strong

          Sending an ECG “out for review’? Where exactly do you practice? I’ve seriously never heard of such a thing. In the hospital, ECGs need to be interpreted in real-time. If there’s a concern that it demonstrates something beyond the skill set or experience of the hospitalist, it prompts a cardiology consult. But the consult isn’t to “review the ECG”.

          • SteveCaley

            All that is worth discussing is that your argument focused on the competence in performing Best Practices. You are in danger at possibly pandering to the very forces that are tearing apart medicine. Please, consider the danger in these assertions you make:
            Everybody knows that “hospitalists are better at, sigh, RIJ cannulation. But “everybody knows that “ENT, vascular and thoracic surgeons are “more competent” at RIJ or LSC cannulation than are hospitalists. Wouldn’t you admit that on the stand, or would you prefer to be torn to pieces by the attorney? In fact, none of these broad assertions is rooted in a scintilla of fact – they are bald generalizations, appeals to a muzzy intuitive wisdom and no more.
            Yes, look at outcome data, consider risks of complications – but do not pin the entirety of that on the identity of the practitioner.
            The people who are stroking you for your “superiority in Best Practices” in 2014 will be the same ones questioning why a PA-H cannot become equally competent in the canned bundle of duties that hospitalist work will become.
            “What is the difference, doctor, between your hands holding the ultrasound and needle, and another person’s holding the ultrasound and needle – who has not had a psychiatry rotation, outpatient primary care rotation, taken the USMLE’s? Was it your undergraduate major in – um, English, wasn’t it? Or the Shakespeare course in sophomore year? Was it the Immunology course in Medical School that made you better at this simple technique. Can’t you set aside your arrogance, and agree that a PA can be equally trained in the three weeks it takes to be certified, doctor?”
            Please understand – contempt and infighting serves only the finance people, the business people, the Government people who are out to crush the life out of medicine. There will be PA-H’s – physician assistant hospitalists. By the time they come out, there will be reams and oodles and tons of data that shows that their performance outcomes are superior to MD’s. Trust me, the data is on the way.
            By history, the ones they pet and approve of at one time, are the ones they take out by the woodshed and shoot the next season. That’s a trend you can count on.

    • HJ

      In depth and longstanding relationships with a PCD is a thing of the past. Primary care doctors don’t see your for simple things or for urgent things.

  • BullDogLizzy

    Isn’t this problem supposed to be addressed by careful communication of issues via a computer record or a chart by the bed? What about overlapping professional and paraprofessional personnel schedules?

  • JustADoc

    I realized later last night that my math was wrong but didn’t have the opportunity to come by and fix it. However my math was also a little wrong for my numbers as well.
    Hospitalists did not exist until 20-25 years ago because Medicare didn’t increase pay for hospital visits and docs couldn’t afford to go anymore. There was nothing special about them and the specialty didn’t arise out of any medical need. It was purely financial.

    • Eric Strong

      “OH, in addition-the hospitalists at my hospital don’t do central lines at all…”

      When I was at a community hospital, most of our group didn’t do our own lines there because it was time consuming and we were salaried – thus we personally didn’t receive extra money for the procedure – it went to the hospital. Instead, it was common to call anesthesiology to place them, which they didn’t mind since they could bill separately for it, and it was easy money for them. For us, it wasn’t a matter of competence or preference, it was simply a time-saving maneuver when overworked, which was utilized because of suboptimal incentivization. At academic institutions and VA hospitals, this asymmetric incentivization isn’t present, and therefore hospitalists (or their medical housestaff) do most procedures.

      “…most don’t do intubation, and they consult pulmonology on all their vents.”

      While I would not expect most hospitalists to perform intubation regularly, they should feel comfortable managing most ventilated patients on their own. Maybe your hospital has some policy in place requiring such consults be placed?

      “And by the way, outpatients have EKGs and CXRs also that have to be acted on in real time. That means the FP reads them.”

      First, the average hospitalist probably reads an order of magnitude more of each of these per year than the average outpt doc. Second, inpt EKGs and CXRs are way more likely to be challenging to interpret, and have a greater diversity of findings than outpt studies.

  • SteveCaley

    The argument draws out into the open a fundamental misunderstanding about the practice medicine that has been growing for many years. The article argues nicely about some of the problems in conventional axioms in medicine; axioms that are energetically (and incorrectly) defended in the comments that follow.

    A properly trained physician is one who can accurately understand what things are within one’s own professional scope of capacity, and what things are not. That is a classical understanding of medicine, and one which has fallen by the wayside in the eternal parade of certification and sub-certification.

    Later on in the comments section, we see a discussion on the benefits of having certified experts hospital practice looks at the cannulation of central veins, when there is a need for such things as high-volume fluid resuscitation and other things where peripheral access is insufficient. There is discussion on placing cannulæ into the readily accessible central veins, and what methods and techniques to use. This argument brings up several points that are worth considering:

    1) The continual improvement of techniques does not render previous techniques incompetent or dangerous. It simply offers a physician a more desirable technique to choose when attempting a maneuver. My residency was biased towards Left IJ cannulation, as it was easer to float specialized catheters into the heart with an IJ cannula in place. Right subclavian cannulation was the alternative; I was glad to do the left Internal Jugular, as I am left-handed and it is a little easier for lefties.
    2) The goal of a procedure, no matter the technique, is to achieve a successful outcome. A LIJ cannulation done without ultrasound is not deficient per se; it is potentially deficient only when it fails. Sometimes, time is of the essence and one must work with what one has. I doubt that my experience in being able to know where the vein is by examination of the surface anatomy, puts me in any weaker position if I wish to learn the US technique, than one trained only on US technique, who is hopelessly lost when the machine breaks. Not to be immodest, but I have never missed an LIJ in dozens of successful cannulations. It is not because I am exceptional, but because I learned how to do it by careful and patient teaching. The anatomy remains fairly similar. One can easily detect aberrant anatomy on physical examination, and call in specialist assistance rather than proceeding with the procedure. An ultrasound is not necessary to warn the provider of a complex or potential problem.
    3) If I am a primary care provider, I know that neck. I have examined that neck a dozen times. My hands know that neck. I have done JVD, HJR, all the tricky things one does looking at the cervical vascular bundle, and many times. I know that neck. Perhaps I would wish to get ultrasound assistance; or perhaps the IJ is just lying there under the surface, big as a finger, and it can’t be missed. Regurgitant atrial pulsations might be calling out unmistakably. It doesn’t take Ultrasound to know the anatomy, in most cases; it only takes the intelligence to know when ultrasound IS needed.
    4) You, the hospitalist, have done 12 LIJ cannulations and 3 RSC cannulations within the last year. In your patient, the LIJ is unsuitable, and the RSC is indicated. You are working in the hospital with two other hospitalists. One has done five RSC cannulations in the last year, the other has done seven. Why do you – the least experienced hospitalist on the team – proceed to do the cannulation? Why didn’t you ask for help, doctor? As we slide into the Best Practices swamp, there need not even be a bad outcome for the patient – just a new regulation that the person on staff with the most experience in each procedure should be called upon to do it. How’s that for over-fragmentation?
    There is a great lust for conformity of opinion now in the medical world. All procedures can be enumerated, and best practices assigned to each of them. The writer dares to point out that coherence and convention of Common Wisdom might not be the best thing for the patient. Fortunately, Common Wisdom is quite skilled at stamping out dissent. Have at it.

    • Eric Strong

      “The continual improvement of techniques does not render previous techniques incompetent or dangerous.”

      Could a general surgeon who trained before laparoscopy was in widespread use justify doing an open appendectomy instead of a laparoscopic one because open appendectomies were the standard of care before laparoscopy was developed? I doubt it.

      “My residency was biased towards Left IJ cannulation, as it was easer to float specialized catheters into the heart with an IJ cannula in place. Right subclavian cannulation was the alternative”

      Thanks for beautifully illustrating my point about the relative competence between specialties. Floating PA catheters is easier from the right IJ and left subclavian, not the other way around. This isn’t an institutional bias – it is universal convention bordering on fact. Feel free to review the NEJM procedure videos, or alternatively, Google chest X-rays with PA catheters, and you’ll see that nearly every example has the catheter entering either the right IJ or left subclavian.

      “…I know that neck. I have examined that neck a dozen times. My hands know that neck. I have done JVD, HJR, all the tricky things one does looking at the cervical vascular bundle, and many times. I know that neck…”

      People’s anatomy sometimes doesn’t match up with what Netter says it should look like – in ways that cannot be reliably detected by external landmarks. I’ve seen more than one example of the carotid lying directly anterior to the IJ that was invisible on exam.

      Routine use of ultrasound in line placement is standard of care in 2014.

      • SteveCaley

        Sorry, RIJ over LSC. My badness.

      • SteveCaley

        I don’t think I was arguing about routine use of ultrasound in central line placement. Improvements tend to occur in medicine, and have done so for many years.
        What has typified the last twenty or thirty years is the capture of medicine by the technocrats and finance folks, and that’s not going away. I want to warn you – in some ways, you are feeding yourself into the hamburger grinder. Please ponder that for a minute.
        We have discussed Best Practices in line placement. We have gone over the list of local resistances to antibiotics at a particular hospital.
        We are rapidly approaching the public question – “Gee, if hospitalist work is just looking up antibiotics on the hospital website, printing out the canned pneumonia “Guidelines” and discharging the patient on-the-clock, why in the heck does it take 12 years of schooling to learn all that?”
        Trust me, it is being asked. Why not have a PA-H? A physician-assistant-hospitalist can take an ultrasound course just like anyone else, get CERTIFIED for the procedure in two weeks or so. Two years after high school should do it – why twelve?
        Once the “Hospitalist” is reduced to a drone performing a canned set of processes, there will no longer be a need for an MD to be performing all these procedures.
        There will be one “Chief Hospitalist” who will the MD reviewing the monthly compliance documentation and taking the legal hits for the avoidable deaths.
        And don’t say “They wouldn’t DARE do that.” Unconscionable things are done by people with no conscience. Consider.

        • Eric Strong

          The fact that you think a hospitalist job could someday be reduced to “a drone performing a canned set of processes” or that we could be replaced by PAs suggest that you have a very limited perspective of what hospitalists do. Maybe the hospitalists that work at your hospital have a very limited scope of practice, and are focused only on showing up on time, writing mindless orders, documenting only what’s necessary to bill insurance companies, and leaving at the end of their shift.

          But the hospitalists I work with:

          1. Secure diagnoses on medically complex patients, which are occasionally exacerbations of chronic diagnoses missed by prior doctors.
          2. Manage these diagnoses, not by blindly following guidelines or treatment algorithms, but by considering the entire context of the illness and patient. This frequently requires reconciling conflicting recommendations from multiple specialist consultants.
          3. Communicate with patients and families; hold family meetings when appropriate.
          4. Transition patients to hospice when appropriate.
          5. Perform (or supervise) procedures
          6. Interpret a broad range of diagnostic tests, including ECGs, CXRs, CTs, PETs, and bedside ultrasound.
          7. Sit on, or chair hospital committees.
          8. Teach medical students and residents in a wide variety of settings, ranging from bedside teaching to large lecture halls.
          9. Design and conduct QI projects and/or clinical research.
          10. Give grand rounds.
          11. Proofread and edit student and housestaff documentation.
          12. Provide timely and constructive feedback to students and housestaff on their performance.
          13. Provide medical consultation and surgical comanagement.


          The hospitalists I know do all that. While individual items on this list could potentially be done better by someone else (e.g. a critical care doc is better at placing lines, a radiologist is better at interpreting CTs, a palliative care doc is usually better at family meetings, etc…), there is no one in or out of the hospital that can perform the grand summation of those responsibilities better than hospitalists. It is implausible to consider we will someday be replaced by PAs.

          I wonder about the environment in which you work that has given you such a limited view of what hospitalists do.

          • SteveCaley

            “…suggest that you have a very limited perspective of what hospitalists do….I wonder about the environment in which you work that has given you such a limited view of what hospitalists do.”
            Friend, read my previous comment carefully. You are constructing an argument to convince me of a perspective which I never took. You will need to come up with an argument to persuade Big Business Medicine of your value – and most of the argument which you offer is worthless in their ears.
            They will hear that you can add better quality to a service at incrementally higher cost. They are uninterested in such things.
            In the ears of Big Business Medicine, though, replacing hospitalists with PA-H’s has quite a merry ring, indeed.
            #1 and #2, the centerpiece of hospitalist duties, can be condensed down into a Diagnosis List and a Treatment List. One looks up the symptoms on the Diagnosis List if one has no diagnosis; or a Treatment List if one has a diagnosis.
            None of the rest is all that interesting to Big Business Medicine, except for the performing of procedures.
            You can marvel at the “grand summation” of all that being a hospitalist entails; but remember, those who neither know nor care what you are talking about will be swayed. “Sit on Committees?” How Doctor Kildare!! The management of the hospital will be done for you, don’t your worry about that.
            Clinical research – yes, that’s a nice way of not working that involves not being paid, think the Chiefs.
            Listen to yourself – you are the perfect “passionate believer” that can be used to squeeze all the energy out of – and then discard. Stalin called them “useful idiots” – again, his words, not mine. Many fine men wound up on the heap this way.
            Look at the ACTUAL problem in its dimensions, not your slice of it – and consider.

          • Eric Strong

            If “Big Business Medicine” is really your concern, I might focus more on your own job security. The role of NPs and other non-physician providers is growing much faster in the outpatient setting than inpatient.

            On that note, I’m invoking Godwin’s Law and ending this thread.

          • SteveCaley

            Very well, then. But the Big Business folks who have come into control of the system, who really pull the strings, relish this sort of vanity and naiveté. “Of course, I am so important, so knowledgeable and skilled – they can never imagine doing without me!!
            When it comes to the lust for power and big money, real money, self-aggrandizing and vain talk like that means it’s time for you to go. What happened to Leon Trotsky, the intellectual architect, with Lenin, of the Russian Revolution? He died of the worst headache of his life, a sudden piercing one.
            Just because an idea is nasty and unthinkable does not make it false. Tell it to the PA Hospitalists who will be admitting and attending by 2017.
            When it comes, who will save you?

          • SteveCaley

            I must confess – I am not familiar with Godwin’s Law. From Wikipedia, I read:
            Godwin’s law does not claim to articulate a fallacy; it is instead framed as a memetic tool to reduce the incidence of inappropriate hyperbolic comparisons. “Although deliberately framed as if it were a law of nature or of mathematics, its purpose has always been rhetorical and pedagogical: I wanted folks who glibly compared someone else to Hitler or to Nazis to think a bit harder about the Holocaust”
            Well-put, but still puzzling. Are you saying, “Whenever two scenarios can be offered, the one with the greatest dependence on human kindness and righteousness should prevail?
            Perhaps, you know, I withhold the benefit of the doubt to Big Business Medicine. All they are trying to do, they promise, is make the system better, safer, and cheaper. Who is to say that they are not telling the absolute truth?
            I shall also surrender to Godwin’s Law of Benevolence, and end my submission here (the following one precedes) Best wishes!

          • Suzi Q 38

            Don’t be so sure about that.
            It may take time, but with all the budget cuts, you can bet administration will find a way to utilize less expensive personnel to treat patients.
            Hospitals will not be exempt.

  • querywoman

    My internist does do hospital work and her office is next to the hospital. I have been in the hospital with her four times.
    I am mostly managed by specialists these days. I see her occasionally to maintain the relationship.
    It’s so nice to have my own doctor in the hospital.
    When I had serious pneumonia that landed me in the hospital 8 days in 2012, she called in a pulmonologist and a cardiologist.
    When I had a milder pneumonia that only got me 2 days in the hospital early this year, she was able to manage it herself. I did see the pulmonologist after I got out and then her her a few days later.

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