The Hospitalist Situation
I'm just wondering if anyone else has this problem or if it's just at our hospital.
We have a team of very capable hospitalists at my facility, to whom I am comfortable admitting practically any medical condition. The problem is that I only work nights, and every other subspecialist at my hospital is as thrilled as I am about our hospitalists' competent medical care. So by the time I come on in the evening, the hospitalist on no doc medicine call has already admitted a huge number of patients (many of whom already have established physicians), and they often ask me to admit any further patients to anybody else but them, or sometimes they just say they can't possibly admit another patient.
So I then must either:
1) call a Cardiologist to admit a soft chest pain rule-out or a Surgeon to admit a weak "partial small bowel obstruction" (otherwise known as gastroenteritis, but whatever works, right?) or a Neurologist to admit an elderly patient with altered mental status or......you get the idea. They will probably ask me to admit the patient to the hospitalist, of course, like all of their colleagues have been doing all day long, thus causing the problem we are now facing at 2 am.
OR
2) hold the patient in the ER until the morning hospitalist comes on call and abuse them with two or three admissions to start the day, thus propagating the problem.
OR
3) Use the ultimate ER weapon, that I tend to save for particularly difficult situations...."I am formally requesting you to consult on this patient. You are on call for this facility, and so you are required to personally come evaluate the patient within a reasonable time and make a disposition or accept the patient to your service. My next call, if I must make one, will be to the chief of your service."
The last choice is a tactic that I would prefer not to ever have to use because I understand the difficult situation each of these physicians are in, and I really don't want to antagonize our future working relationship by forcing the issue. In my opinion, if the specialists would use the hospitalists more sparingly and appropriately during the day, we wouldn't have to make all of these difficult decisions (and multiple phone calls) late at night.
Why should the hospitalist admit a patient at noon who already has an established specialist and who would probably benefit from the specialized care of an expert who is already familiar with them and who will be assuming their care after discharge? And then the specialist gets stuck admitting some patients who really would be better evaluated by a hospitalist?
It just doesn't make sense to me; maybe we just need more hospitalists. After further consideration, however, I think I know why it happens. The patients with established specialists are more likely to be insured, so of course the hospitalists are eager to take care of those patients. And if they "max out" with hits by midnight, and the poor Cardiologist, Surgeon, or Neurologist has to actually evaluate a nonpaying patient, then that is just how the cookie crumbles. When in doubt, follow the money.
Another problem is that we don't even have an unassigned Gastroenterology or Pulmonary Medicine call schedule (despite very active services by both specialties), so typically patients that could be admitted to those specialists are instead routinely admitted by our hospitalists. I'm not sure how those specialists get away with not taking unassigned call, but they do, so our hospitalists get slammed with all of the GI bleeds and asthmatics too. I can't use the last arrow in my quiver against a specialist who really isn't "on call" because his shield is impenetrable.
We have a team of very capable hospitalists at my facility, to whom I am comfortable admitting practically any medical condition. The problem is that I only work nights, and every other subspecialist at my hospital is as thrilled as I am about our hospitalists' competent medical care. So by the time I come on in the evening, the hospitalist on no doc medicine call has already admitted a huge number of patients (many of whom already have established physicians), and they often ask me to admit any further patients to anybody else but them, or sometimes they just say they can't possibly admit another patient.
So I then must either:
1) call a Cardiologist to admit a soft chest pain rule-out or a Surgeon to admit a weak "partial small bowel obstruction" (otherwise known as gastroenteritis, but whatever works, right?) or a Neurologist to admit an elderly patient with altered mental status or......you get the idea. They will probably ask me to admit the patient to the hospitalist, of course, like all of their colleagues have been doing all day long, thus causing the problem we are now facing at 2 am.
OR
2) hold the patient in the ER until the morning hospitalist comes on call and abuse them with two or three admissions to start the day, thus propagating the problem.
OR
3) Use the ultimate ER weapon, that I tend to save for particularly difficult situations...."I am formally requesting you to consult on this patient. You are on call for this facility, and so you are required to personally come evaluate the patient within a reasonable time and make a disposition or accept the patient to your service. My next call, if I must make one, will be to the chief of your service."
The last choice is a tactic that I would prefer not to ever have to use because I understand the difficult situation each of these physicians are in, and I really don't want to antagonize our future working relationship by forcing the issue. In my opinion, if the specialists would use the hospitalists more sparingly and appropriately during the day, we wouldn't have to make all of these difficult decisions (and multiple phone calls) late at night.
Why should the hospitalist admit a patient at noon who already has an established specialist and who would probably benefit from the specialized care of an expert who is already familiar with them and who will be assuming their care after discharge? And then the specialist gets stuck admitting some patients who really would be better evaluated by a hospitalist?
It just doesn't make sense to me; maybe we just need more hospitalists. After further consideration, however, I think I know why it happens. The patients with established specialists are more likely to be insured, so of course the hospitalists are eager to take care of those patients. And if they "max out" with hits by midnight, and the poor Cardiologist, Surgeon, or Neurologist has to actually evaluate a nonpaying patient, then that is just how the cookie crumbles. When in doubt, follow the money.
Another problem is that we don't even have an unassigned Gastroenterology or Pulmonary Medicine call schedule (despite very active services by both specialties), so typically patients that could be admitted to those specialists are instead routinely admitted by our hospitalists. I'm not sure how those specialists get away with not taking unassigned call, but they do, so our hospitalists get slammed with all of the GI bleeds and asthmatics too. I can't use the last arrow in my quiver against a specialist who really isn't "on call" because his shield is impenetrable.
Labels: ER, medical, nightshifts
posted by scalpel at 7:18 AM
14 Comments:
I have thought multiple times about the hospitalist situation and have been employed both as an internist and a hospitalist. Here is how it plays out typicaly in most hospitals....some history first..
In the beginning hospitalists were hired by hospitals and a percentage of their salary was paid by the hospital. The hospital actually saved money because length of stay and quality of care would improve and this would improve the hospitals bottom line. The hospitalist on the other hand, having 20-30 percent of their salary paid by the hospital itself would be able to make the rest of their salary up by billing for patient care. This would allow each hospitalist to see 10-12 patients a day and give excellent care. Hospitalists programs would then also hire new hospitalists as their numbers swelled.
The tide however has changed. Hospitals have now decided that they don't need to pay any bit of the hospitalsists salary even though they are making money on their existence. Therefore hospitalist programs require their hospitalists to see many more patients (16-20) a day to cover their own salaries.
If a hospitalist program has too many docs...it won't have enough business and won't be able to cover salaries. So what happens is most programs run on as few docs as possible. On busy days these docs who are woefully undersatff see as many people as possible but towards the end of the day they get to the tipping point and can't possibley see more. Why then don't they hire more docs? simple....on quiet days they will have to many and will lose money. better to run bare bones and turn down business then to be overstaffed and lose money.
Who loses in this situation? Everyone!
I am the dinosaur here, and firmly believe that the advent of hospitalists is the work of the devil! I have never spoken with a general surgical colleaague who is happy with the hospitalist system at their institution. In my experience, it is system that reverts to a pure shift-work mentality, with a complete lack of continuity of care.
Unfortunately, the system is here to stay. While it may not seem palatable, I would have to say that if they are on call, and you need them to admit a patient whose problem lies within their bailiwick, they have no reason to complain. They made the system and signed up for it.
Tell the hospitalists to suck it up and admit the patients since they are on call. After all, that is the rule, correct? However, I do foresee that this will be a recurring problem for you that needs to be stomped out. The rules must be clear. All you need to do is call the Chief of Medicine and punt the ball over to his court. Works for me all the time. Let him adjudicate over his department.
If it's 4 am and my choices are to hold a patient in the nearly emptied ER for 3 more hours for the next day's hospitalist or wake a chief of service, cause a political battle, admit my patient to a grudgingly accepting, exhausted, overworked, pissed-off super-busy hospitalist who will never forget that I did that to him, making my life more unpleasant every time I call him from that point on....I would rather choose my battles carefully.
When in doubt, I always try to do what's best for the patient.
We had the same problem at my joint starting about 18 months ago.
This is a short-term problem for you, if you do it right. Every time you awaken the Neurologist / whatever make sure you get in that you wouldn't be calling them except that the hospitalist is getting crushed...
The hopsital will start with their motivational "work harder, work faster" but there's only so many hits a day an Internist can take.
We had the same thing, and the hospital has bulked-up out hospitalists to 3 shifts in the ED a day, and not because the ED wanted more bodies, but because the specialists told them they needed more help. It's not perfect (what is) but it's a lot better than a couple of years ago.
So, this too shall pass. Don't piss anyone off, but you already know that. Heh.
GruntDoc
I appreciate everyone's advice. Thanks for commenting.
I was very skeptical at first when our staff instituted hospitalists. Shortly after, I operated on a man with AIDS, long cared for by an excellent doc in town, one of the few who'd see AIDS patients. The man had perforated a lymphoma of his jejunum. I operated, and he did well, and kept asking when his doc would be seeing him. I thought it pretty awful that his long-time doc would no longer care for him in the hospital. Over time, I changed: the hospital team are a group of excellent docs, and whereas there are many docs in town quite capable of excellent hospital care, many are not. And I sympathize with the economics of the office docs. So I came to like the hospital team, in that they were good, and always available. They grew to a surprising number, and eventually had three or four working at all times. They provide good care. The "shift" mentality is a definite drawback; continuity is often difficult to maintain. But trying to get hold of a hospitalized patient's primary doc or -- more often -- the doc covering for the primary doc, is no more satisfying. I worked for a while as a surgical hospitalist, after my "retirement," and I loved it: purely a surgeon. Patient care 100% of the time. And the medical hospitalists loved having a surgeon so available. (I was the first they'd had...)
Erm... Scalpel, do you mean that all the times when the junior ED docs tell me it is definitely a partial small bowel bowel obstruction, that "you can see it on the X-ray" (when the X-ray shows no such thing) and that profuse diarrhoea and vomiting are the hallmarks of a small bowel obstruction... do you mean to say that the ED docs are knowingly playing the system? Until now I'd always thought they just didn't understand the difference between gastroenteritis and a small bowel obstruction. Because they're so insistent, you see.
Gee.
Silent Pause.
I'm gonna have to rethink my entire world view.
Love your blog.
(And sorry that this comment doesn't provide useful advice on how to improve the system.)
Hey butterfly! I'm sure there are some docs who don't understand (or can't figure out) the difference, but ultimately we are probably all just trying to help our patients the best we can.
If the radiologist calls it a partial small bowel obstruction, then who am I to argue? ;)
Ultimately, if a patient keeps vomiting after antiemetics, or if they have comorbidities or social circumstances that make sending them home a risky proposition, then I don't really care which service admits them. I personally will usually call the internist first though. But I always appreciate the generosity of a surgeon willing to take one of these "soft" surgical admissions when I need someone to do the right thing for a patient.
Pancreatitis, some cases of diverticulitis or the new onset of terminal ileitis are other examples of the "tweener" diagnoses that can go either way.
Good points! Although I must confess that I'd be laughed at (or yelled at) if I suggested that any cases of pancreatitis or diverticulitis go to the medical docs. Perhaps things are different where you are. :)
Unless the diverticulitis is associated with abscess, or the pancreatitis is particularly nasty, I would get laughed at by most surgeons here if I tried to admit such cases to them. Gallstone pancreatitis in particular routinely gets admitted to the internists, with GI consult for ERCP, then a surgery consult for cholecystectomy.
Unless there is an operation that will more than likely be required, most surgeons in my experience would rather act as consultants.
Probably half or more of all the hip fractures get admitted to a medical service at my current hospital, to manage the perioperative and longstanding "medical issues."
Weird.
Interesting! If a patient appears in my ED with gallstone pancreatitis they will be admitted under surgery. End of story. Even if they've got cystic fibrosis, haemophilia, diabetes and a recent heart-lung transplant (or any other potentially complicated condition requiring medical knowledge). As far as I know it's the same all around Australia.
At the last hospital I worked in the chief medical administrator sent around a memo stating that any patient who presented with abdominal pain who required admission must be admitted under a surgical bedcard. The surgeons were aghast but the administrator stated that even a surgical consultant was not permitted to refuse admission of a patient with abdominal pain. (Gotta love administration...)
For a time this led to entries in the notes from the general surgical registrars along the lines of:
"While this man presented complaining of upper abdominal pain, I feel this is due to his RLL pneumonia and as there is no evidence of abdominal pathology on examination or investigation perhaps the medical team may be happy to admit him. We would be most happy to consult and offer surgical management for his pneumonia as required."
"While this man presented with epigastric pain, I am concerned that his abnormal ECG, significant cardiac history and elevated troponin suggest a non-abdominal cause for his pain. Perhaps the cardiology unit would be prepared to admit him. As we have no cardiac surgery services it may be necessary to transfer him to another hospital if surgical management is desired. We would be most happy to provide advice in this matter if required."
You get the idea. The memo from administration, incidentally, came after the surgical teams kept refusing to admit patients with profuse diarrhoea and non-surgical abdomens. As far as we know there were no incidents relating to patient care, but the ED consultants were most peeved when we (the surgical teams) repeatedly stated "we are not the gastroenteritis doctors" and set out to prove to us that, in fact, we are the gastroenteritis doctors.
But that's okay. We're all doctors. We can treat gastroenteritis if we have to...
Here's an idea. How about the patient's physician act like one and come to the ER to admit the patient if they are on call. Or better yet, if they are too lazy, tired or negligent to take care of patients at 2am then maybe consider another field. Or better yet, since the hospitalist is actually doing them a favor.. or should I say a SERVICE, why not do what is customarily done in American, PAY FOR THAT SERVICE. Why should the patient pay? It's the lazy doc on call who doesn't want to come in who is getting the free ride. Hospitalists should start charging admitting fees to the docs they are giving the sleep too. Wallah, a new American industrial first. I love it. I think I'll start!
I must say that as a caregiver I detest the hospitalist system. In our area, docs who take ongoing care of patients are loathe to "step on the toes" of the hospitalist, even when requested by the patient or family. As a result, critical information falls through the cracks, which sometimes leads to inappropriate care. My loved one's GI specialist hates this system, and I do, too, as I believe it has lead to his premature deterioration and lack of will to live. We aren't cases, we're people.
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