Medscape article by Shelly Reese
A Relationship That Could Improve
The state of the relationship between hospitalists and primary care physicians has hit a nerve.
In her video, “Primary Care and Hospitalists: Improving the Relationship,” Dr Pegus, director of the Division of General Internal Medicine and Clinical Innovation at New York University Langone Medical Center, underscores how two forces reshaping the face of medicine—the rise of hospitalists and the consolidation of outpatient practices into larger heath systems—present an opportunity to enhance care by improving physician communication.
But there’s a challenge. The situation is not quite there yet.
What’s the Ultimate Vision?In their comments about Dr Pegus’ video, frustrated physicians indicated that the open communication and coordinated care she describes are not yet the reality they experience. As for the professional collegiality Dr Pegus describes, that may be even more aspirational.
The vision of a collaborative relationship depends upon hospitalists and primary care physicians working within a given health system having access to the same information. In addition to a common electronic medical record, they need a shared understanding of the evidence-based guidelines standardized throughout their health system. They need training programs that educate physicians about the tools available to them; face-to-face meetings and onboarding events so they can meet each other; and clear, supportive messages from leaders underscoring, “This is how we’re all going to work,” she says.
“Because these physicians all work within the same health systems, it’s extremely important that there are great communication modalities set up so that all of the physicians within a health system are hearing the same message,” Dr Pegus says.
The Feedback: When Will This Become a Reality?
Logical though the message and the ultimate outcome may be, many Medscape readers say that closed-loop communication system doesn’t yet exist.
“It would be wonderful if the system worked as outlined, but it doesn’t,” writes one internist. “The ER doc admits the patient. The hospitalist basically does a holding job and passes the patient off to another hospitalist in the manner of a shift worker. Each doctor seems to assume that the other doctors have contacted the primary doctor for an in-depth discussion.”
Frustrating as that may be for physicians, it’s even worse for the patients who get the runaround, the writer complains, citing the case of one of his own patients. She “told me that a hospitalist came into the room, did not touch her, and said he’d be back. He never came back.” Instead, a second physician cared for her after a specialist said that she could be discharged. Yet another hospitalist came and discharged her. “Then she came to see me. The ER note and the specialty consult gave me the info,” he writes. “The EHR info is generally useless.”
Frustration That the Ideal Is Not Yet Reality
An internist echoed the same sentiment. “Hospitalists are simply a convenience who, in my experience, do little to contribute to better patient care. They have no stake in the game with a sole role of filling the gap and seeing that paperwork gets done. I wish I’d see more passion, but instead they seem to do just enough to get by. I’m sure there are exceptions, but in community-based HMOs and smaller hospitals, most doctors are just trying to survive the ever-increasing administrative demands.”
It’s unclear whether the physicians responding to the Medscape video work within health systems that use the processes described or whether they are affiliated with less integrated systems, but a common theme characterizes their remarks. Multiple readers, while recognizing the efficiencies gained through the hospitalist approach, complain that they come at too high a cost to patients. One reader notes that “hospitalists appear to be the protectors of the hospital administrators,” rather than partners to the primary care providers outside and trusted caregivers to the patients they treat.
“Many of the discharge summaries I’ve read written by them are dismal at best, and the patients just don’t seem to feel safe when rounded on by a different physician every day with whom they have no history,” writes one reader.
A seasoned emergency medicine specialist provides a perspective from within the hospital and laments that the system provides a dysfunctional, impersonal care model that runs counter to the goals of patient-centered care.
“Back in the day it was very common to help our colleagues admit a patient, write the orders, and even round on them at the end of a shift to be certain that all was well,” the doctor writes. “The primary care physician took the best care of the patient because he or she knew the patient. Today, with multiple shifts of in-patient hospitalists, no one really knows the patient, and the care suffers. Just ask any older nurse on the med/surg floor. I understand efficiencies, costs, etc., but patient satisfaction scores suffer.”
A family medicine physician complains, “The abandonment of hospital medicine by primary care physicians has been one of the worst contributors to patient care that I have seen in my 34-year career,” while an aggravated internal medicine physician lashes out with an open letter. “Dear hospitalist,” he writes. “If I call you on a patient, please listen and integrate, as I do have some understanding of why the patient is finally in the hospital. Please include in the discharge summary some accurate thought as to why everyone who is admitted gets the same treatment: IV fluids and antibiotics, Lasix and antibiotics, or steroids and antibiotics. Thank you.”
What’s the Upshot?
It seems that there is work to be done.
Although the communication channels Dr Pegus outlines may still be aspirational for many health systems and their physicians, the move toward hospitalist coverage for inpatient care continues to gain momentum. As she notes, hospitalists are the fastest-growing medical specialty, and health systems are unlikely to forfeit the many benefits hospitalists afford them.
In light of that, health systems and the hospitalists and primary care physicians they employ have a communication gap they must bridge.
For Dr Pegus, that call to action is “an opportunity.” Patients might call it a necessity.
As for doctors, for the moment, they call it “very forward-thinking.”
Medscape Business of Medicine © 2016 WebMD, LLC
Source: http://www.medscape.com/
Posted by: The Wealthy Doctor
Permalink: http://wealthy-doctor.com/hospitals-and-primary-care/