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ICH turf, "glorified housestaff?"



Published in the January 2010 issue of Today's Hospitalist

Managing ICH patients: It’s about turf
In my facility, the hospitalist service admits all non-surgical intracranial hemorrhages (ICH). We did not have a choice: The neurosurgeons refuse to admit a nonsurgical patient, and general surgery and neurology claim it is not in their scope of practice.

The truth is that neurosurgeons are trained to manage these patients, and the bottom line is that no one wants to get out of bed. What you call a “paradigm shift” in your December 2009 cover story, I call “turf.”

I resent this shift, but I think it will be transient. With cost and reimbursement cutbacks, payers are NOT going to continue to pay two doctors when only one is needed. Hospitalists will not be paid to manage hypertension in an ICH patient when the appropriate admitting doctor (the neurosurgeon) has for years been capable of doing so.

With hip fractures, comanagement has been shown to improve outcomes, but that’s not the case with ICH. Why are we charging extra health care dollars to let the doc who has traditionally managed the case sleep in? It’s time for hospitalists to stop wasting money and for specialty services to step up, practice in their scope and stop dumping patients so they can sleep.

Todd Painton, MD
Appleton, Wis.


“Glorified housestaff”?
Your publication is one of the few that I routinely read every month, but there seems to be some editorial complicity in the fact that more and more cases are being deferred to hospitalists for admission.

Your December 2009 From the Editor noted that “respect from other physicians” received one of the lowest scores in a recent survey. You wondered whether we could expect that to rise as we take on more admitting services.

I think the answer to that question is “no.” We are often seen as little more than glorified housestaff as we admit patients more appropriately admitted by a specialist. The only thing we accomplish is to improve specialists’ lifestyle—at the expense of providing appropriate, timely care.

I have a broad policy at my hospital: Any patient requiring specialty intervention, whether procedural or cognitive, should be admitted by the appropriate specialist. We are always willing to facilitate a specialty admission by consulting and to transfer patients to our service when specialty issues have been resolved. But the patient is admitted to the specialist’s service, and I find it disturbing that your publication seems to advocate for a paradigm that, in my experience, is dysfunctional and dangerous.

Mike Flowers, MD
Knoxville, Tenn.

Editor’s note: Today’s Hospitalist takes no position on whether or not hospitalists should take on more admitting service lines.
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