Thursday, January 1, 2009

I hit a raw nerve with Hospitalists

I do not get why the contributors on "Happy Hospitalists" are so angry at me!

At least one person on that blog (which I still respect) suggested that I "haunt ivory towers." Nice and very professional.

(FYI: I "haunt" these teaching hospitals because I am a cancer patient and I also care for my elderly dad who is a Stage 4 cancer patient. And, that my dear doctors is the basis upon which I comment on the hospitalist system, among other aspects of the delivery of medical care. This is a system that has both healed and injured myself and my dad. I see chinks in your armour and I hope it can be fixed.)

It is sad that hospitalist supporters are not concerned about patients being harmed by hospitalists at some very fine institutions.

It is also very sad is that anyone (regardless of their credentials) would throw personal insults at patients that have been injured or who have ill family members. That is just unacceptable and unprofessional. And if anyone hurling personal attacks at a patient's story is a physician, they should be ashamed and look for a different profession.

Yes, I know what a "hospitalist" is supposed to be. I am thrilled that apparently some hospitalist programs run like a fine tuned machine. But the reality (yes, boys and girls, reality) of the hospitalist program model is that it is not a finely tuned machine at all institutions.

I have experienced the "hospitalist program model" from the inside. I have experienced it as a patient and patient advocate/care-giver.

I certainly understand the basic premise that a hospitalists is a physician that specializes in hospital medicine. A doctor admits his patient into a hospital and then in-patient care is followed day-to-day by a hospitalist. (I have written posts on my blog explaining the concept hospitalist without commentary. If people do not think that I know what a hospitalist is then they simply have not read the blog.) I also understand that the hospitalist program model includes resource managers that are theoretically supposed to ensure a smooth discharge and continuity of care post discharge.

Okay, that idea that it saves PCPs and clinicians time and money to have a hospitalist program sounds simple enough. But, there are problems - big major problems - with that seemingly simple system.

1. Not all attendings are hospitalists.

That is just a fact. And, because I do not go through life "anonymous," I give facts that I am willing to stand by and back up with my name. (One of my favorite blogs, The Happy Hospitalist, has demonstrated that its easy to insult anonymously.)

At Duke University Hospital, a surgeon can be an attending and there is also a hospitalist. That happens if and when a patient (or patient's family) demands that their loved one be cared for by the clinical doctor that recommends hospitalization.

In the case of my dad's hospitalization at DUH last month, Mark E. Easley, M.D. was dad's attending physician during the hospitalization. Dr. Easley is not a hospitalist. Dr. Easley is a terrific orthopedic surgeon.

Dr. Easley (a non-hospitalist) called the shots and the shots were carried out by residents, fellows and presumably the hospitalist.

The hospitalist was not in charge of my dad's case. The hospital doctor was also a resident and took orders from the attending, non-hospitalist Dr. Mark Easley.

Hospitalist (and non-attending) resident bluntly ignored attending physician Dr. Mark Easley's order to have urine cultures taken of my dad. (Dr. Easley knows of my dad's medical hx and propensity to have serious UTIs.)

Hospitalist (and non-attending)
resident told me that taking cultures was not cost efficient. The resident said he had UA done for my dad and it was negative. I asked the hospital resident whether it was his routine to ignore an attending's orders. The resident told me that his job was to be cost efficient.

After learning that the resident only performed UA prior to dc, Dr. Easley told me to take dad to his personal urologist post dc. Dad had a very serious UTI that only showed up on cultures. In that one (of many) situations, the hospitalist refused to cooperate with the attending.

Alas, there is (at least in my experiences) sometimes a difference between an attending physician and a hospitalist. Have I made that clear enough? Have I written slow enough for everyone to understand?

There is a similar problem with admitting doctors "handing off" the patient to the hospitalists and the hospitalist ignoring the reason that the patient was admitted.

2. Hospitalists refuse to cooperate, communicate and coordinate with clinic physicians.

My dad has been hospitalized at DUH about 10 times since April 2007. I was there at every hospitalization. I was there almost 24/7. I talked with hospitalists, nurses, technicians.

At each and every hospitalization, the hospitalist told me to my face that they would not communicate with dad's oncologist clinician.

I spent hours on the phone with dad's Duke clinic doctors to get advise. Many times, the Duke clinic doctor would come to the hospital and see dad and review what the hospitalist was doing.

On occasion, the Duke clinical doctor advised me to get dad out of the hospital or take him to a different hospital to get away from the particular hospitalist. One time (September 2008), the oncologist's clinic office advised me to "fire" the particular hospitalist because she was doing more harm than good.

You can fire a hospitalist by contacting the hospital administration (risk management) and talking to them.

My dad has had more serious complications when hospitalist were involved. I describe those situations in detail earlier in this blog.

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Perhaps the hospitalist model is a good one. Maybe DUH is an unfortunate anomoly. But I have had other physicians at great teaching hospitals (like Northwestern) tell me that the hospitalists fight for turf.
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I am suspicious about the treatment I have received by hospitalists or those in favor of the model. I joined a post about me on a blog frequented by hospitalists and I was attacked, insulted. Why? It makes me think that I have stumbled onto something that hits a nerve.

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I absolutely know what it takes to be a FMG. I was a practicing immigration attorney and helped FMGs get work authorizations. Some were great doctors. Some were not. (Just like U.S. medical school grads.)

I am just trying to understand why a physician would choose hospital medicine as a career. I thought maybe it was the fact that they were physicians that for some reason (language barrier or personality) are unable to create and maintain a loyal clinical practice.

Me" A Bigot? Hardly. But when it comes to patient safety, I am looking for answers. And I refuse to be politically correct in the quest. Period.
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I just passionately care about patients. I do not hate hospitalists. I wish that the hospitalists at DUH had cared about my dad. I wished that I had good experiences with the hospitalist model. But I haven't.

And I want to do two things:

1. Make sure patients understand that generally your PCP will not care for you in the hospital and why. I doubt that most people even understand that there PCP probably will not follow them in the hospital.

2. Make sure that where the hospitalist program model exists, it does good and not evil! If the hospitalist program model is workable then perhaps it should be standardized (so that it works as well as it apparently does in some places).

I am seriously shocked that hospitalists are not disturbed that some hospitalists are ruining the program. I hate when attorneys are crooked because then it gives the professional a bad scar.

All of the sticks and stones will not shut me up. Sorry. We, as consumers of medical care, entrust doctors and hospitals with our lives. Doctors and hospitals must treat all patients with appropriate medical care, respect and dignity.

I want to return to graduate studies to be able to help patients. Patients are being hurt everyday in hospitals throughout the US. It hurts my heart to have patients suffer. And, at least at DUH, hospitalists are in part responsible for hurting patients.

A prayer for us all:

God bless and protect the good, caring physicians in this world. And, God bless those of us who care day in and day out for sick loved ones. God please grant we, the care-givers, with the personal strength and fortitude to fight for those in our charge and to remain unfettered by any member of the medical community who seeks to discourage us (or who insults us).



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