Most hospitalists are good, but some, like these ones, aren’t

It’s a well known phenomenon that hospitalists are taking over inpatient medicine.

And no wonder, the payment system strongly discourages newly minted doctors to practice outpatient medicine, and the demand that hospitals have for inpatient physicians is surging at an unprecedented rate.

It’s a good time to be a hospitalist, but, as this reader writes to me, that may lead to an increasingly variability in the quality of care. Here’s an account:

I work in a small hospital where the primary care docs have stopped seeing their own and a hospitalist group has taken over.

The level of care the hospitalists give is very poor. They spend less than 30 seconds in each room. We play a game by timing them with the second hand of our watches — 25 seconds, tops, for most of them. They pile all the charts at a computer, walk into room after room for less than 30 seconds, make no notes, write nothing down anywhere, often don’t touch the patient, then they leave and go directly into the next room. They visit ten to twelve rooms in a row in exactly the same manner, then sit at the computer and write in chart after chart. It is astonishing.

Next, the name of the game is, how many tests can they order? The geriatrics who are failing, in their 80s and 90s, come in and get everything from echos, CT scans, MRIs, carotid and venous dopplers, all possible labwork, etc. Their H&Ps are a list a mile long of terminal fatal conditions, but the list of diagnostics and treatments they get is equally long. Some get complete neurology work ups for their natural loss of consciousness as their life ends. Yesterday I watched 2 COPD’ers put on a vent, each one got an echo, several x-rays, one a dobhoff [feeding tube], both got PICC lines, then inhaled morphine to deal with their terror. They were both managed by hospitalists.

It is frightening and unbelievable to be in the trenches and watch this.

I’m not sure this is endemic of hospitalists as whole. Hopefully not. But I do think this is simply a consequence of how doctors are paid in general, and not limited to hospitalists.

Volume is the name of the game, and the payment system actively discourages doctors from spending time with patients, or performing detailed physical exams for that matter. It’s much easier and faster to order tests and imaging studies, which apparently, is what’s happening here.

As physician and hospital payments continue to be under pressure, I suspect that what’s being described here will slowly, if not already, become the norm. Simply put, doctors will make up for lost revenue by seeing more patients and ordering more tests.

The entire physician payment system needs to be reformed to change this behavior. Any type of health care reform will be rendered impotent without such action.

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