To those brave souls who have returned after digesting last week’s cheerleading on hospitalists, here is the Achilles’s heel of the system. While the advantages are clear and substantial, there are serious vulnerabilities which have not yet been adequately remedied.
Achilles Held by the Heel Being Dipped into the River Styx
- Hospitalists cannot appreciate the medical nuances, personality, family dynamics, life events and prior experiences that may be well known by the out-patient physician.
- There are serious communication lapses, all of which cannot be bridged. The out-patient doc may know that the patient’s chest pain is his typical anxiety and that it is not necessary to repeat the cardiac evaluation that was done 2 years ago. The hospitalist may take a different tack here.
- Despite their best efforts, hospitalists know that they will not be seeing the patients after discharge. As they are not permanently vested, they may not address certain patient concerns, punting these to the outpatient arena. While this may be medically acceptable, it may be frustrating for some patients.
- The hand off back to the out-patient doc after hospital discharge can be a minefield. Patients may be on new medications. They may have had a variety of laboratory and radiology tests. Some of these results might be ‘pending’ at the time of discharge. How does the out-patient physician reliably receive these results and understand their context? Did medical specialists on the case leave recommendations that the primary physician now has to track and implement? When the primary care doctor resumes care of a patient who had a complex hospitalization, is he now responsible to search out and address every loose end contained within the voluminous hospital record? Could a single laboratory abnormality buried in the record that was totally unrelated to the medical illness become a medico-legal issue years later? Do we really think that the hospitalists discharge summary to the primary care physician is airtight?
A primary care physician recently complained to me that the local hospitalists never call him when his patient is admitted when he might provide useful information about his patient that only he know. This is a legitimate gripe.
No system is perfect
So, over the past 2 weeks you have been offered a fair and balanced presentation on hospital medicine. Which side of the issue has the better argument?