Primary care has lost its quarterback position in patient care



There is a crisis in primary care and that crisis is now
flowing over into the hospital when a primary care physician’s (PCP) patient is
admitted. No longer cared for by the PCP, the role has largely fallen to the
hospitalist. There has been a loss of the long time primary care physician-
patient relationship, the trust that comes with time. There has been a frequent
loss of satisfactory communication when the patient is admitted and again when
discharged.  At a time when the patient
most wants and needs the comfort of a long time trusted professional friend,
the patient instead is confronted with a stranger at the helm. What has
happened to this create state of affairs?

PCPs have seen their overhead costs rise dramatically along with insurer
mandated paperwork and government mandated electronic medical record (EMR) time
requirements. This means the PCP must see more and more patients for shorter
and shorter periods to cover overheads and reserve time for the nonclinical
requirements. The average visit time is now 15 minutes with only 8 to 10
minutes of “face time”. It also means that most – but definitely not
all – PCPs no longer attend their patients in the hospital, leaving that
function to the hospitalist

Hospitalists are trained in caring for patients in the
hospital. Since that is all that they do, they become very experienced in
dealing with the types of medical issues that require hospitalization. Working
full-time in the hospital means that they know how to get things done in that
setting and do so fairly efficiently. The growth of the hospitalist movement
over the past twenty years has been truly phenomenal – at 50,000 physicians it
is the largest medical sub specialty (cardiology is next at 22,000), surpassed
as a specialty only by general internal medicine at 109,000 and family medicine
at 107,000.
Early studies suggested that quality was improved and costs
reduced with the advent of hospitalist care. This was especially true for
complicated patients who required multiple physician visits and interactions
each day, something difficult for the community based physician to achieve. And
with the need to see multiple patients each day in the office to cover
overheads, many PCPs willingly ceded hospital care to the hospitalist. 

In our experience hospitalists are a heterogeneous group, many are just out of
an internal medicine residency; some are working part-time because of childcare
obligations. Many are contemplating a fellowship but want to catch up on loan
obligations. Some hospitalists anticipate at a future point to become PCP’s.
Still others intend to make a career as a fulltime hospitalist.

Frequently employed by the hospital, they still must meet productivity
standards in order to earn their salary.  Often this means caring for a
large number of patients, most of them quite ill. Although they are expert in
what they do, they do not have the years of interaction with the patient that
the PCP has. And so they did not know the patient before the hospital event and
are not likely to know him or her after. 
Each patient is an individual with his or her unique family, social,
economic and of course medical background. The patient today may well have
multiple chronic illnesses such as diabetes, congestive heart failure or
chronic lung disease and now enters the hospital with a new problem or an
exacerbation of an old one. The hospitalist can deal well with the reason for admission.
Nevertheless they will not be cognizant of the fine balance of personality and
medication that has otherwise maintained the patient as independently living in
the community.  It also unlikely that
they know what studies have been done prior to the admission. 

In recent back to back articles in the New England Journal
of Medicine, Wachter
and Goldman
along with Gunderman present
rather different perspectives on the rise of the hospitalist subspecialty yet
the decline of comprehensive care. 

 

Our observations of routine hospitalist care is that a given
patient may have multiple hospitalists over the course of the admission rather
than one doctor who knows the patients well. In a four-day stay a patient may
easily be cared for by three different hospitalists. Test redundancy and
unneeded consultations are all too common.

There is also a tendency to ask for consultations from subspecialists
when more time with the patients might have been sufficient to establish the
issue at hand. Fever-infectious disease, pneumonia-pulmonologist, chest pain – cardiologist.
 Relatively easy procedures are also handed
off to a specialist, e.g., joint effusion – call the orthopedist to do the arthrocentesis.  Mildly demented patients all too often get a
repeat head scan because of an inadequate handoff that the patient has already
had a more than adequate evaluation for reversible causes of dementia. Typically
a hospitalist service is made up of many physicians that have a minimum of
three years of internal medicine training. We are not sure if the statistic
exists but in many community hospitals the average number of years of
experience after residency is likely less than five years.  So if an unusual problem arises, call for a
consult. There typically are multidisciplinary rounds but the admitting hospitalist
may not be the rounding physician. 

More discouraging is the finding that hospitalists tend to
place the primary care doctor’s patients often on the wrong medication, very
often there is inadequate communication between the hospitalist and the primary
care physician to review details at the time of admission. This of course can
lead to a more extensive hospital stay. To compound the problem, the handoff
back to the PCP at discharge is often problematic with inadequate communication
between them. The PCP may not even know that the patient was admitted or
discharged until the patient calls for a new appointment. Meanwhile, the fine
balance of those chronic illnesses may be out of kilter so that, not
surprisingly, about 20% of older individuals end up back in the hospital with
an unplanned admission within the following month.

The PCP was always the backbone of American medicine. He or she not only cared
for patients in the office but also collaborated with the emergency room
physician and attended to hospitalized patients, seeking specialist
consultation as needed. Today, only a few PCPs even visit their hospitalized
patients, relying entirely on the hospitalist and the emergency medicine
physician.

Hospitals are scary places. You never really want to be
admitted but sometimes it is necessary and indeed even lifesaving. This is the
time when you most want a knowledgeable professional friend of long standing,
one you with whom you have deep seated trust.

Although most PCPs do not visit their patients in the hospital today, some do
and they are committed to give the patient the expert care that the patient
requires. But for these physicians some community hospitals for various reasons
have determined that only the hospitalist may have privileges to care for the
patient. That’s right; hospital managements are discouraging primary care
doctors from coming to the hospital and in many cases have prohibited them from
having active admitting privileges.  Somehow,
they discount the possibility that the primary care doctor knows the patient best
and can work effectively and collaboratively with the hospitalist for the
patient’s benefit. Erroneously, hospitals in many cases believe that primary
care doctors diminish quality and increase the length of stay. We have
discussed this very issue with a retired board member from a large Maryland
insurer and confirmed that a huge 
uncontrollable expense to the hospital bill is over consulting with specialists
and redundancy of procedures and testing ordered by hospitalists.

The PCP is being marginalized. This is distinctly to the patient’s
disadvantage.

Interestingly insurers are having an impact on control of
costs but not in the hospital. Primary care physicians are now rewarded for
guiding patients to the less costly specialist and using visiting nurses to manage
co-morbidities that have saved
hundreds of millions of dollars
. We believe now the insurers need to
understand the value of comprehensive primary care that extends into the hospital;
this would translate into even more savings. PCPs need to earn enough with a smaller panel of patients that they can
afford to care for fewer patients but with greater time spent with each as
appropriate including visiting their hospitalized patients, working
collaboratively with the hospitalist and interacting with the emergency
medicine physician. Insurers (including Medicare) need to dramatically reduce
the unnecessary paperwork and requirements so that the PCP can actually spend
time with the patient.

We are not intending to disparage hospitalists. They are
well trained, committed and productive and overall have added quality to the
hospital environment. We are advocating however for a collaborative process of
hospitalist and PCP working together. Returning the PCP to his or her positon
as the quarterback of patient care is good medicine; it means greater quality,
a more satisfied patient, less frustrated physicians yet much lower total costs
of care. A win-win-win.

Harry A Oken MD, who coauthored this post with Dr Schimpff, is a
primary care physician in private practice who still cares for his patients
when hospitalized and is a clinical professor of medicine at the University of
Maryland School of Medicine.

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