Sunday, July 2, 2017

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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Praise for Dr Schimpff

The craft of science writing requires skills that are arguably the most underestimated and misunderstood in the media world. Dumbing down all too often gets mistaken for clarity. Showmanship frequently masks a poor presentation of scientific issues. Factoids are paraded in lieu of ideas. Answers are marketed at the expense of searching questions. By contrast, Steve Schimpff provides a fine combination of enlightenment and reading satisfaction. As a medical scientist he brings his readers encyclopedic knowledge of his subject. As a teacher and as a medical ambassador to other disciplines he's learned how to explain medical breakthroughs without unnecessary jargon. As an advisor to policymakers he's acquired the knack of cutting directly to the practical effects, showing how advances in medical science affect the big lifestyle and economic questions that concern us all. But Schimpff's greatest strength as a writer is that he's a physician through and through, caring above all for the person. His engaging conversational style, insights and fascinating treasury of cutting-edge information leave both lay readers and medical professionals turning his pages. In his hands the impact of new medical technologies and discoveries becomes an engrossing story about what lies ahead for us in the 21st century: as healthy people, as patients of all ages, as children, as parents, as taxpayers, as both consumers and providers of health services. There can be few greater stories than the adventure of what awaits our minds, bodies, budgets, lifespans and societies as new technologies change our world. Schimpff tells it with passion, vision, sweep, intelligence and an urgency that none of us can ignore.

-- N.J. Slabbert, science writer, co-author of Innovation, The Key to Prosperity: Technology & America's Role in the 21st Century Global Economy (with Aris Melissaratos, director of technology enterprise at the John Hopkins University).