Why is your hospital always full? Actually, it’s more than full. You have twenty boarders in the ED. You turned your postop recovery unit into an overnight surge center. Every day administrators beg you to please, please discharge patients, if possible before 11 a.m. You’ve hired an army of case managers, dissected the discharge process, and held countless capacity management meetings, but you’re still bursting at the seams.
It wasn’t always like this, was it?
Here’s a thought to shake you up: maybe your hospital is full because your hospital employs hospitalists.
To understand why this might be true, we need to go back 25 years, before there were hospitalists. Caring for hospitalized patients was the responsibility of everyone. The day-to-day schedule of most physicians back then looked something like this: Wake up early, round on inpatients, go to clinic to see outpatients, and return to the hospital to see new inpatients. If that sounds like a lot of work, it was. It was one of the many things I found unsustainable about primary care. I lasted four years as a PCP before I knew it was time for a change. I’ve been a mostly happy hospitalist since.
As bad as it was, there was a benefit to the old system that seems to have been forgotten. Physicians who were responsible for their inpatient care cared very much if their patient was admitted. Of course, they still care, because physicians are caring people, but they cared differently back then because they were the ones doing the admitting.
Now, you might think that sick patients are sick patients and admissions shouldn’t depend on who is on call, but you would be wrong. Really sick patients get admitted no matter who is on call. Borderline sick patients can go either way. And it’s that borderline sick population that makes all the difference when it comes to census.
Consider the case of a 74-year-old woman with pneumonia. She’s frail and lives alone, but isn’t especially ill. The ED physician doesn’t know her and thinks admission is the safest thing to do. But it turns out that her PCP is on call. She knows the patient well, and knows that despite her condition, she can safely go home. So the ED physician and the PCP talk. Maybe that talk is spirited. In the end, instead of admitting the patient the PCP arranges home health care and a follow-up appointment in the morning. It’s a lot of work, but maybe that’s the best thing for the patient. And it’s almost certainly less work than admitting the patient.
Of course, I could slant the story to make a more convincing case for admission. That’s the thing with borderline sick patients; they can go either way. I’m not accusing anyone of malpractice or even laziness; I’m just suggesting that in the old days physicians were less motivated to hospitalize borderline sick patients, because — shocker — no one wanted to get out of bed in the middle of the night.
Now let’s fast forward to 2019. In the primary care world, we’ve largely divided providers into those who see outpatients and those who see inpatients. We call those inpatient providers hospitalists. Most specialists still see patients in both settings, but many exclude their inpatient practice to consultant work only, leaving hospitalists as the primary provider in charge.
The new story goes like this: The same patient calls her PCP for a fever. He considers seeing her tomorrow, but doesn’t want to cram another appointment into his already packed day. The PCP sends the patient to the ED, knowing full well that if she requires admission, the ED won’t call him. The ED provider diagnoses the patient with pneumonia and sure enough calls the hospitalist to admit her. Here’s the thing about the hospitalist: It’s his job to admit patients. That’s why he was hired. Maybe he isn’t convinced the patient needs admission, but unlike the PCP he doesn’t know the patient, so he has less of a case if he wants to push back. And he remembers the last time he had a spirited discussion with the ED. It didn’t go so well. The ED physician called the hospitalist’s boss, who called the hospitalist to remind him that he was hired to admit patients. So the hospitalist does his job and admits the patient.
If you don’t think this happens every day; ask any ED provider who worked before and after the hospitalist era. Most will tell you it’s way easier to admit patients now. They don’t have to argue with an exhausted PCP, desperate to get a few hours of sleep before clinic. They call a hospitalist working a 12-hour shift, who sort of happily admits the patient, then goes home.
The same thing happens in the specialist world. A nephrologist wants to start a patient on dialysis. Maybe he’s mildly fluid overloaded. He needs a dialysis line placed and an open slot in a dialysis unit. Managing him the outpatient setting would be a lot of work, but in the old days, so would admitting him, because the nephrologist would be the one doing the admitting. Now? Calling the hospitalist to admit the patient is way less work.
Think about where we stand: We have several hundred thousand PCPs and specialists who have lost some degree of motivation to keep their patients out of the hospital. Hospitalization is not their job anymore. We have over 50,000 hospitalists who are reasonably motivated to hospitalize patients. It is their job. Do the math, and it’s easy to see how we inadvertently tipped the scales towards admission.
Still wonder why your hospital is full?
There’s hope that the new, new world of value-based care will de-incentivize expensive decisions like hospitalization. Perhaps. We’ll still have the hospitalist path of least resistance and providers may choose less work over more money.
Regardless of which way the motivation pendulum swings, what we really need to know is this: Should we or should we not hospitalize our 74 year-old with pneumonia? What’s best for her?
Steve M. Grant is a hospitalist.
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