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On Being a Doctor |

Three Degrees of Separation

Howard Beckman, MD
[+] Article and Author Information

Note: The name and the details of care have been changed to protect the patient's anonymity.

Requests for Single Reprints: Howard Beckman, MD; e-mail, hbeckman@RIPA.org.


Ann Intern Med. 2009;151(12):890-891. doi:10.7326/0003-4819-151-12-200912150-00011
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In February 1994, Ms. Sampson's emphysema was causing shortness of breath, which limited her activities. I advised her to call if her respiratory symptoms worsened. Two days later, she did. I saw her in the office, began treatment with oral steroids, advised an increase in her rescue β2-agonist inhaler, and started antibiotic treatment.

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Three Degrees of Separation
Posted on December 17, 2009
Sriram S. Narsipur
SUNY Upstate Medical University
Conflict of Interest: None Declared

Dear Dr. Beckman, I have just finished reading your essay in the Annals. In my case, I am a nephrologist and not a "primary care" doctor per se. However, as you know, I have long term relationships with my patients extending years before and after their admissions. It seems now that the admission stands alone; that there is no past or future for the patient. I rarely get called by the ED or admitting hospitalist despite the fact that I can often facilitate care of the patient and expedite discharge on the basis of seeing the patient at dialysis 3 times a week. The essence of what has been lost, in my mind, is a sense of relationship and deeper meaning in what we do. The existing incentive assumes we are driven by monetary gain rather than our belief that we can mean something to patients even when we don't have a pill or test for them. I congratulate you on an excellent series of insights. I anticipate physicians will understand well what you are writing about. I worry that administrators, policy makers, and decision makers will not.

Conflict of Interest:

None declared

Hospitalists
Posted on December 20, 2009
P. Dileep Kumar
Port Huron Hospital
Conflict of Interest: None Declared

Dr Beckman details his experience with hospitalists managing his hospitalized inpatients. Hospitalist practice does fragment patient care in some ways. However, in this day and age, patients see multiple physicians in the outpatient setting fragmenting the care process. A recent study reported that Medicare beneficiaries saw a median of 2 primary care physicians and 5 specialists working in 4 different practices1 in a year. All of these doctors are likely to order more tests and medications. The role of primary care internists has slowly been transformed into that of a care coordinator, rather than a mystique physician who miraculously diagnoses and cures unknown diseases. The advancement of technology, a plethora of specialists and the over- utilization of diagnostic tests have contributed to this. The emergence of hospitalist services is another facet of the same evolution. Contrary to Dr Beckman's experience, several internists using hospitalist services report higher satisfaction, reduced interference of routine work and a boost in revenue.

However, it is important to preserve internists' right to see their own patients in the hospital if they so chose. Professional associations of internal medicine physicians have a role to play in accomplishing this. The hospitalist movement is still evolving and definitely has several issues, alluded to by Dr Beckman. Another important point is that, similar to emergency medicine, hospitalist medicine has the potential to become a separate specialty. This might lead to further disintegration of internal medicine. It is the responsibility of internal medicine physicians and leaders to work with hospitalists to keep them engaged rather than denouncing them for all the shortcomings of the current system, which include complex issues such as communication and hand-offs.

References

1. Pham HH, Schrag D, O'Malley AS, Wu B, Bach PB. Care patterns in Medicare and their implications for pay for performance. N Engl J Med 2007; 356:1130-9.

Conflict of Interest:

None declared

Fewer Degrees of Separation
Posted on December 26, 2009
Mark J. Ault
Cedars-Sinai Medical Center
Conflict of Interest: None Declared

As an academic general internist of similar vintage as Dr. Beckman I sympathize with his sense of loss of the "old days", a time when the general internist was the true utility player seeing patients in the office and following them through the emergency department, in and out of the intensive care units and discharging them back to the office. Admittedly, those days are gone and no rearrangement of incentives is going to bring them back. Medicine and hospitals have gotten too complicated. However a relatively simple incentive with a modest financial investment may help shore up a more patient centered health care team. If office based physicians were required to provide, could bill and be fairly reimbursed for a hospital visit the day of admission and the day of discharge, incentives would be established to encourage "skilled explicit transitions of responsibility", to integrate the primary care doctors as an integral member of the health care team and to instill in patients a true sense of continuity care. The explicit point of the visit would be to close information gaps that occur as patients move from one point of the system to another.

While the immediate response to this suggestion would likely be focused on yet another cost in an already cost prohibitive health care system, we need only examine the costs of fragmented patient care relative to the benefits gained by eliminating potentially detrimental and demoralizing "degrees of separation". We can do better!

Conflict of Interest:

None declared

Can we do better in time?
Posted on December 29, 2009
Robert L. Young
National Jewish Health
Conflict of Interest: None Declared

To the Editor:

I couldn't agree more with the observations and concerns raised by Dr. Beckman (1) in his recent essay. Though 15-20 years his junior, I initially practiced as a traditional internist in a rural community. I was the primary care doctor, the inpatient attending, and the critical care physician for my patients and delivered good, comprehensive care. Shortly after entering practice, our group developed a hospitalist program. We did and it worked well, as we remained engaged with our patients, even when not serving as the inpatient attending. This seemed a beneficial system for all parties.

I subsequently accepted a position as a hospitalist in a larger integrated health care system and soon became a non believer in the hospitalist model. The physicians I now worked with had never been outpatient physicians, discounted the value of long-term relationships with patients, and ordered tests that frequently seemed unnecessary (assuming the patient had a capable outpatient physician). Our outpatient physicians rarely visited their hospitalized patients and often seemed perturbed if I interrupted them to update them on a patient. Eventually, I realized that the general internal medicine I loved had died in the short time between my internship and my first 5 years in practice (which coincided with the explosion of the hospitalist model). Now, having completed a pulmonary and critical care medicine fellowship and being in a predominantly basic research oriented position, I have a niche practice in adult cystic fibrosis care that approximates the image I have of the doctor/patient relationship as it should be. However, I mourn the fact that I am no longer the internist that so many patients need.

Hospitalist programs have benefitted hospitals, insurers, and physicians who want a lifestyle, expecting the privilege of being a physician to come without the inconvenient hours those who do it well know it requires. I believe patients have suffered despite outcomes literature suggesting improvements in care. I know I took much better care of my patients when I was their full time physician than I ever did when meeting them for the first time as a hospitalist.

We must do better, but how tragically bad must our entire systembecome before we recognize the need for change? A good first step will be restoring caring for the patient as our primary goal.

References:

1. Beckman H. Three degrees of separation. Ann Intern Med. 2009;151:890-1.

Conflict of Interest:

None declared

The Bigger Picture
Posted on December 31, 2009
Michael D. Stillman
Boston Medical Center
Conflict of Interest: None Declared

Dr. Howard Beckman's "Three Degrees of Separation" speaks brilliantly to concerns over hospitalist care, yet in so doing questions the very "soul" of modern medical practice. How do generalists see to the full spectrum of our patients' medical needs? What is lost as we partition inpatient from outpatient care? How has inter-physician communication come to be regarded as an unexpected courtesy rather than an obligation? Why do so many physicians seem to regard one another as bungling adversaries rather than colleagues in a shared struggle?

The night before I read this piece, I received an embarrassing email. One of my patients--a 90 year old lady with hypertension, diastolic heart failure, diet-controlled diabetes, and severe chronic low back pain had been admitted to a local hospital after a fall. She was confused, hyperglycemic, volume depleted, and in renal failure, all likely stemming from a urinary tract infection. Although she had been admitted to a hospitalist service and been seen by several physicians, no one had called to inform me of her hospitalization or to discuss her care. The embarrassing email was from her son, asking why he hadn't heard from me and whether or not I was comfortable with his mother's treatment plan.

When I called the on-duty hospitalist, she was unfamiliar with the critical details of the case. She did not know my patient had had an infection and hence believed her acute deterioration was due to a medication regimen on which she had been stable for years. She was unaware my patient had heart failure, so had glibly discontinued her ACE- inhibitor, beta blocker, and diuretic with no plan to re-institute them. Finally, she was unapologetic about her team's lack of communication, arguing that the emergency room physician should have called me discuss the admission, and that she had been planning to contact me after she had discharged my patient. The conversation was chilling, and Dr. Beckman's observation that he had been regarded as "the local medical doctor from whom the patient needed to be protected" was fresh in my mind.

Dr. Beckman's assessment of hospitalist medicine is even-handed. He rightly argues that use of hospitalists may promote best practices, improve efficiency, and reduce medical errors, yet emphasizes that our current system is disjointed, isolating, and leaves patients feeling abandoned. Yet the truth toward which he nudges his readers is that the difficulties of the hospitalist movement actually pervade our entire profession, and they are simply the outcroppings of a medical community in flux.

Hospitalists exist because we have tacitly agreed to cede ultimate responsibility for our patients to others. We don't cry foul when hospitalists or subspecialists fail to communicate with us because we have accepted the premise that inter-physician consultation is a burden rather than an opportunity to learn, build collegial relationship, and improve how we care for our sick patients. We are unsurprised when a hospitalist or a consultant unilaterally changes a medical regimen because we have allowed our trainees to treat patients as if they live in a medical vacuum, rather than a complex and often deep history of therapeutic failures and successes. Finally, in allowing the practice of medicine to become so sub-specialized and compartmentalized we have surrendered many of our diagnostic and therapeutic skills and much of our medical authority. Imagine regarding inpatient and outpatient medicine as virtually separate fields, and believing that one cannot competently provide care in both venues!

Dr. Beckman is correct in asserting that "we simply must do better." Change, however, begins at home, and each of us must decide what we will and will not tolerate.

Conflict of Interest:

None declared

A hospitalist's perspective
Posted on January 8, 2010
Tarang Sharma
UH Case Medical Center
Conflict of Interest: None Declared

Before joining my endocrinology fellowship I used to work as a full time hospitalist in Columbus, Ohio. This essay reminded me sharply of my days as a hospitalist and how at times I used to starve to learn from patients who they really considered their primary care physician just so that I could pick up the phone and get the bigger picture about the patient. Many times patients were unfortunate to not have a primary care physician, but at other times even more unfortunate enough to be so confused about the fragmented primary and subspecialty outpatient care they received that they did not know who to call their primary anymore.

I realize that physicians never did get paid to communicate with each other and probably never will. Something as essential as 'the human touch' will never translate into any material measurement of appreciation that we know of. Yet, the science of medicine cannot be practised effectively without knowing and practicing the art of medicine. The critically ill need a rapport with the hospitalist to make decisions of code status and life care issues with confidence. Similarly, sometimes digging a little more into 'recurrent CHF exacerbation due to non compliance' is required to effectively tackle a 'frequent flyer'.

Sometimes it is okay to just practice medicine. Sometimes it is okay to just feel good about the grateful look we receive from the patients and their families for going the extra mile. Sometimes, it is okay to not worry more than necessary about reimbursements and overheads. Sometimes it is okay to be a bit idealistic. And for all those who do it this way it will not matter which 'system' they work for - the 'new' or the 'old'.

Conflict of Interest:

None declared

Three Degrees of Separation
Posted on January 8, 2010
Carl H. Reynolds
Rochester General Hospitalist Group
Conflict of Interest: None Declared

To the Editor: We appreciate and echo Dr. Beckman's appeal for improved collaboration between hospitalists, primary care physicians and administrators in his essay "Three Degrees of Separation" (1). He eloquently indicts the discontinuity created by Hospital Medicine, and it bears attention by all physicians.

Primary care is among the most difficult jobs in American health care - the hospitalist model evolved partly to relieve that stress. However, as a result, medical care is a team endeavor now more than ever. The care improvements this team delivers, though, are often hidden while patients and their PCPs acutely feel the pain of discontinuity. This grief pervades Dr. Beckman's writing, but it should not: the efficiencies gained by PCPs, focused in their offices, allow them to touch and heal more patients than was previously possible. Older PCPs comment that their careers are lengthened by hospitalists (personal communication).

Communication lapses hurt all involved. Hospitalists study care transitions (2-4), and work to improve them. Last summer, Rochester General Hospitalist Group started tracking communication with PCPs using an innovative computerized system. Tracking our data and providing individualized feedback led to a tripling of our communication frequency in the last six months.

Despite the "voltage drop" in information that occurs on care transitions in our institution, hospitalists (in partnership with our referring PCPs) have lower mortality rates, shorter length of stay, lower inpatient costs and lower readmission rates than docs who "do it all." Specialization brings benefits to patients, physicians, institutions and payers.

Certainly, alprazolam and head CTs are harmful when inappropriately utilized. Without timely access to the ordering physician's notes and rationale, questioning their use is entirely appropriate. However, instead of seeking to protect "our" patient from our partnering physician on the other side of the hospital wall, we must create systems such as electronic medical records that give that partner prompt, useful (and thereby reassuring) information.

Lastly, the relationship between hospitalists and PCPs is complex. From one perspective, the hospitalist is seen as a service provider for the PCP, with the burden of communication on the hospitalist's shoulders. We argue that a professional relationship, requiring mutual responsibility, serves patients better. Perhaps soon, bundling of payments (5) will generate shared reimbursement incentives, further encouraging collaboration. Hospitalists must respect the primacy of the patient's best-known provider and engage PCPs to improve care transitions. There is much exciting work to do; we thank Dr. Beckman for emphasizing its importance.

References

1. Beckman H. Three Degrees of Separation. Ann Intern Med. 2009;151:890-1.

2. Pistoria MJ, Amin AN, Dressler DD, McKean SCW, Budnitz TL, The Society of Hospital Medicine. The Core Competencies in Hospital Medicine. J Hosp Med. 2006; 1 Suppl 1:83.

3. Snow V, Beck D, Budnitz T, Miller DC, Potter J, Wears RL, et al.. Transition of Care Consensus Policy Statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine. J Hosp Med. 2009 July/August; 4(6): 364-370. JGIM 2009

4. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in Communication and Information Transfer Between Hospital-Based and Primary Care Physicians. JAMA 2007; 297(8)831-841.

5. Hackbarth G, Reischauer R, Mutti A. Collective Accountability for Medical Care - Toward Bundled Medicare payments. N Engl J Med. 2008 Jul 3;359(1):3-5.

Conflict of Interest:

None declared

In response to Beckman
Posted on January 19, 2010
Robert M. Wachter
University of California, San Francisco
Conflict of Interest: None Declared

Beckman's thoughtful manuscript raises important questions regarding communication between hospitalists, patients, and primary care physicians. The field of hospital medicine continues to work on improving communication and transitions. As might be expected, there are hospitalists programs that communicate superbly, while others do it less well -just like every other specialty, and every other specialist.

Beckman's piece also raises the question of whether hospitalists might actually raise hospital costs through redundant testing. Virtually all the relevant studies have demonstrated that hospitalists decrease overall hospital costs (1-3). Approximately half of American hospitals now have hospitalists, and more than 90% support the practice with hospital dollars (2,4). Given the dominant DRG payment system, to argue that hospitalists are wasting money (overall) would be to argue that hospitals are acting against their interests by supporting their hospitalist programs. This seems unlikely. More likely is that hospitalists do order some repeated or unnecessary tests, but save more money by driving hospitalizations forward, gathering data, coordinating in-hospital specialists, building better systems, and following guidelines.

And while memorable but anecdotal stories about unhappy inpatients who long for their primary care doctor will always be there, every published study that has examined patient satisfaction under hospitalist systems has shown neutral satisfaction (i.e., no overall worsening from the primary care inpatient model to the hospitalist model), at worst (1).

Try this for a thought experiment: Imagine we were transitioning from a hospitalist-based system of inpatient care to one involving primary care physicians (i.e., the old system). I'm certain we would hear of cases in which patients felt abandoned because their doctor saw them at 6:30 am but not for the rest of the day; or patients felt that their care was completely uncoordinated since there was no "quarterback" in the hospital; or there were unnecessary tests or incorrect decisions because of the primary care physician's lack of knowledge of evidence-based inpatient guidelines. In other words, the old model was flawed as well.

Dr. Beckman acknowledges that he voluntarily agreed to use hospitalists and he is not prepared to reassume hospital care, despite his reservations. He is not alone. So the right question to ask is how to improve coordination and make the hospitalist model as good as it can be, for all the involved parties. Without question, such improvements continue to require work, which is why hospitalists around the country are attacking these issues with such passion (5).

References

1. Wachter RM, Goldman L. The hospitalist movement 5 years later. JAMA 2002; 287:487-94.

2. Wachter RM. Reflections: the hospitalist movement a decade later. J Hosp Med 2006; 1:248-52.

3. Harrison JP, Curran L. The hospitalist model: does it enhance health care quality? J Health Care Finance 2009; 35:22-34.

4. Kuo YF, Sharma G, Freeman JL, Goodwin JS. Growth in the care of older patients by hospitalists in the United States. N Engl J Med 2009; 360:1102-12.

5. Arora VM, Manjarrez E, Dressler DD, Basaviah P, Halasyamani L, Kripalani S. Hospitalist handoffs: a systematic review and task force recommendations. J Hosp Med 2009; 4:433-40.

Conflict of Interest:

None declared

Focus of a Patient's Care
Posted on April 12, 2010
Richard M. Plotzker
Private Practice
Conflict of Interest: None Declared

To my surprise, neither Dr. Beckman nor the many respondents noted that the primary physician may not be the physician who directs a patient's care. For dialysis patients the dominance of the nephrologist seems obvious. There are many patients with diabetes, asthma, inflammatory bowel disease, et. al. who consider their doctor to be the one who takes care of the dominant illness. To a great extent, the hospitalist trend has divorced us from our role. It is not unusual for me to learn of my diabetic's presence in the hospital the patient telephoning from his hospital bed or from the family informing my secretary when she calls to remind of an upcoming appointment. I have gotten calls from patients at the pharmacy asking me why their new insulin costs $400 when their HbA1c has been reasonably therapeutic for twelve years for $30. Unfortunately, when I track down the hospital prescriber, which may take multiple calls, the reason has more to do with a convenient box to check on a protocol sheet than a well-considered medical reason for the revision.

We like to think that we take care of patients but sometimes we really process them through instead. It is difficult to capture a perspective of a patient in a few days in the hospital, where three hospitalists may write on the order sheet for two days each. Most chronic illnesses are indeed chronic. They evolve over time. Those of us who have guided that care are too often left aside, sacrificing years of thoughtful care to get through a few days.

Richard M. Plotzker, MD Endocrinology Wilmington DE

Conflict of Interest:

None declared

hospitalists and outpatient physicians must meet in the middle
Posted on April 15, 2010
David Carl Houghton
Banner Good Samaritan Medical Center
Conflict of Interest: None Declared

I read with interest Dr Beckman's essay on his disappointment with the state of hospital medicine. Having once practiced full spectrum primary care as he did, admitting my own clinic patients and caring for them after discharge, I can empathize with his dismay, and I agree with his portrayal of the subtle but important losses that occur when vulnerable patients are taken care of by physicians that are not familiar with them, and who do not have the longitudinal incentives to become familiar with them that their primary care physicians do. I eventually left the 'do it all' model of comprehensive primary care and became a hospitalist because the outpatient world increasingly viewed my determination to stay active in the hospital as a drag on clinic efficiency and productivity. I felt increasingly that I was being pressured to make a choice between the hospital and the clinic. In the end I decided that caring for the sickest patients was where my skills and interests led me. Since becoming a hospitalist, I have shared Dr Beckman's dismay, but from the other side of the mirror. I confess that I mostly stopped trying to contact primary care physicians long ago, because so often, after considerable effort to get through office phone systems and front desk staff, I would finally encounter a primary care physician whose demeanor suggested that my call was distracting him or her from the busy clinic flow, and who seemed all too eager to end the conversation as quickly as possible with an abrupt, "Well thanks for letting me know." My efforts to communicate discharge plans were often met with an attitude that seemed to humor me, but did not at all reassure me that my faxes were of any interest to the practioner they were being sent to. I agree with Dr Beckman that much improvement is needed in our current model of hospital medicine. That improvement will require outpatient practices to contribute just as much as hospitalist groups if patients are to be cared for as they deserve to be. The inpatient/outpatient interface is a two-way street, as they say. Primary care providers and hospitalists must meet in the middle.

Conflict of Interest:

None declared

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