The relationship between ER physicians and the hospitalists is often…let’s say complicated. The two physicians often have a completely opposite agenda. In a nutshell – ER doctor thinks that everybody coming to ER should be admitted to the Hospital. The hospitalist, in contrast, thinks that there is never a good reason for an admission.

Let’s look at things from the ER physician standpoint first. The ER doctor has to facilitate patient flow in the ER. Otherwise, the waiting room will be overflowing with people, waiting time will be long and the patients will be grumpy. You send the patients out of ER either by discharging them home, if they are not too sick, or calling the hospitalist to admit them, if there is a good reason for it. This sounds simple enough. In real life, though, there are a lot of patients falling into the grey area. The patient might not have a good indication for an admission, yet not quite ready to go home. And that’s where the problem begins – the ER doctor is not comfortable sending patient home, the hospitalist does not see a good reason for admission. The problem is made even worse by a heavy workload for both physicians.

From the hospitalist’s perspective, the patients are often admitted to the hospital for no good reason. Things are rarely straightforward and sometimes it takes time and effort to do the right thing for the patient. Talking to the patient, looking into the old medical records and communicating with the patient’s family takes time. If the ER physician is not quite sure what is wrong with the patient, calling the hospitalist IS the path of least resistance. Some ER doctors even get creative when trying to “sell” admission to the hospitalist. There is always a mysterious pneumonia that nobody can see on the chest XR, otherwise, known as ER pneumonia or NOmonia. Some patients are being admitted for obstipation or “failure to thrive”. Occasionally, the ER doctor will tell you that he has no idea what’s wrong with the patient and is just not comfortable sending the patient home.

I don’t know how many times I was told – “Just watch the patient overnight”. The thing about “watching somebody overnight” is that it often requires the same (or even more) amount of time as a regular admission. The next day, somebody will have to discharge the patient, which takes yet more time for something that could have been done on an outpatient basis.

This is a hospitalist blog and I might not be entirely fair to the ER doctors. I welcome ER physicians input into this problem. After all, why can’t we all just get along?

We all strive to provide excellent care to every single patient in the hospital regardless of the social status, insurance and income level. Yet, sometimes, a VIP patient, be it a city official or a local football star, is admitted to the hospital and everybody tries to go the extra mile to provide even better care. Better care could be the enemy of good care and in my personal experience, going the extra mile might, actually, lead to a worse outcome and this is why:

The hospital is like a big well-oiled machine. Every unit and every person in the hospital has their own routine. On the level of an individual physician, everything from seeing patients, interacting with nurses, ordering tests and reviewing labs goes according to an individual routine. It might be different for every doctor, yet it is necessary to provide consistent care and not to miss things.

Going the extra mile might interfere with that routine. Additional tests might be ordered and multiple consultants get involved “just to cover the bases”. Eventually, it becomes a situation with too many cooks in the kitchen. Physicians could be writing contradictory orders and things are being missed since everybody assumes that it is somebody else’s responsibility to follow-up on things. The heightened level of anxiety around the case might make physicians “to think outside the box” and lead to overdiagnosis and overtreatment.

Sometimes, it is better to fly under the radar and let people do their job the way they do it best.

Several Physician Types You Might Encounter in the Hospital

The Hospitalist movement is a relatively new development, yet it is becoming increasingly popular. Hospitals of every size are introducing hospitalist programs to provide inpatient care. Even though, there are multiple benefits to having a hospitalist team in your institution, there is one obvious drawback – the patients, for the most part, are unable to choose the treating physician. Instead, the patients are usually randomly distributed at the morning report. From a patient perspective that means that they will get “stuck” with whoever is on that day.

There are several types of inpatient physicians that I have encountered in my practice.

Here they are:

The Academician
This physician has a tremendous amount of theoretical knowledge and is able to give you a lecture on any given topic in medicine. Unfortunately, all this knowledge does not always translate into good patient care. The “human aspect” of medical care often irritates and annoys these physicians. This type of doctor does better in an academic practice.

The “Nerd”
This doctor enjoys his/her work and strives to provide excellent care for the patients. He is always excited to talk about an interesting medical case or problem. This type of a doctor tends to overmanage the patient by trying to address every single issue before discharge. For this reason, the patients often stay longer in the Hospital since “there is just one more thing to fix before they go home”. In general, the “nerd” spends a lot of time in the patient room and is often being involved in conversation not directly related to the patient’ medical condition. This takes a lot of time and often makes for very long rounds for this doctor.

Mr/Ms Efficiency
This kind of a doctor knows what he or she is doing and tends to concentrate on the most important issues. If the patient is admitted with pneumonia, there is no reason to order an MRI for chronic back pain since it could be done as on outpatient. This type of doctor tends to redirect the conversation with the patient while taking the medical history. Sometimes, it is necessary to interrupt the patient if the conversation is going nowhere. Despite all of this, the patients usually are quite satisfied with their care since things are being done quickly and efficiently. The patients are in and out of the Hospital which is good for the patients and the bottom line.

The OCD
This Doctor takes everything personal. Unexpected adverse outcome might cause a significant amount of stress for this physician. Patient care is excellent but at a cost of personal distress and even marital problems for this doctor. This doctor is always late to leave the hospital which adds even more problems. There is always something going on and the inability to flip the switch and go home makes this physician miserable.

The “Lone Ranger”
This kind of a doctor is suited best for working night shift. Routine rounding and interaction with the patient and the family is not his thing. If the hospitalist program has one or two of those physicians, developing a nocturnalist program may be a good idea.

The Slacker
This type of a doctor is simply dangerous. The physician does not really know what he or she is doing and doesn’t really care. The notes are often unreadable and pretty much useless. It’s a total nightmare to assume care of the patient after this physician signs off the service. Often, the patient will tell you more about what is going on than the sign-out from this doctor. The patients are often kept in the hospital longer just so that somebody else can discharge them once this doctor is off the service.

These are just a few “extreme” types of the doctors you will encounter in the inpatient setting. This “classification” is based on work ethics and attitude towards patients. These are not meant to address doctor’s personality traits. Doctors, like everybody else, could be classified as whiners, complainers, angry type or even psychotic.

In reality, most of us represent a mix of the types described above. We all have a little bit of everything (yes, even lazy type) and different parts of our personality come up depending on the circumstances. Well, it’s like that saying: “Nobody is perfect”.

I read a very interesting editorial from Annals of Internal Medicine by Dr. Beckman: “Three degrees of separation”. This article brings a very important issue of the ‘separation’ of the primary care physicians from their hospitalized patients. In his paper Dr. Beckman, overall, supported the hospitalist model, yet expressed his concerns regarding the lack of communication and collaboration between the hospitalists and the primary care physicians.

I work with a hospitalist group and, personally, I fully support the current model adopted by most hospitals in US. Medical care is becoming more complicated and specialized. New medications and technologies are constantly being introduced into clinical practice. There is no way to keep up with all the new developments unless you focus on a specific segment of the medical practice, like caring for the hospitalized patients.

I believe that the hospitalists are better ‘equipped’ to care for the hospitalized patients. I am not saying that primary care physicians provide inadequate care. It’s just that there will be enormous pressure on the entire medical system to become more efficient. Running between the hospital and the office might not be economically viable going forward. I see even more specialization in the future. Even within a relatively young subspecialty, like critical care medicine, the sub-subspecialties are being developed: neuro-critical care, cardiovascular critical care etc.

Having said all of this, I realize that the system is not perfect. Communication and continuity of care remains a major issue. It is not a good practice to ‘protect’ the patients from their Family Doctors. Collaboration and direct communication will enhance medical care and will keep the patients out of the hospital.
It is up to the individual hospital and the hospitalist group to develop protocols and directives facilitating direct communication. For example, talking to the PCP on a phone prior to the patient’s discharge home might solve some of the problems.

Dr. Beckman also brings an important issue of the misplaced incentives in our current system. I agree that doing paperwork and talking to the family on a phone is not reimbursed and, thus, not ‘encouraged’. We do it because we want to provide the best care for the patient and this should be driving our motivation.