Published in the April 2015 issue of Today’s Hospitalist
A FORMER PRIMARY CARE PHYSICIAN who used to follow her patients into the hospital, Dale Vizcarra, MD, now works solely as a hospitalist. She can easily reel off both the benefits of hospital medicine and its “real holes.”
Yes, as a hospitalist, she can focus all her energy on patients who are not only “sicker than they used to be” but also “demand more knowledge and discussion.” But she insists that hospitalists shouldn’t kid themselves that something genuine “in terms of both continuity and motivation “has been lost since primary care physicians left the hospital.
That’s why Dr. Vizcarra, who works at Avera St. Mary’s Hospital in Pierre, S.D., was excited to read a proposal in the Jan. 22 issue of the New England Journal of Medicine (NEJM) on how to bridge the primary care-hospitalist divide.
In fact, she sent a copy of the article to her hospital system’s administration, seeing it as ammunition to bolster her campaign to implement virtual visits with primary care doctors during patients’ hospital stays. Bringing the primary care doctor back to the hospital ” via Skype, Apple’s FaceTime or any other video-chat service “”would improve continuity and provide reassurance to patients that their primary doctor knows what is going on with them,” Dr. Vizcarra argues. The hospital system is exploring ways to make such virtual visits a reality.
And while electronic medical records can bridge some of the divide, they aren’t the whole answer. “Even if you have all the records, you don’t get the subtle meanings and catch all the red flags,” Dr. Vizcarra explains. “Patients’ signs and symptoms don’t always declare themselves clearly. Unless you communicate with the outpatient physician, you have no way of knowing what worked and what didn’t work five years ago when the PCP back in the clinic tried what you are proposing to do.”
Moreover, some doctors argue that the commitment hospitalists feel toward their patients is fundamentally different than that of primary care physicians.
Paul Abramson, MD, has worked both as a do-it-all family physician and as a hospitalist. He currently maintains a private primary care practice in San Francisco while moonlighting nights and weekends as a hospitalist.
As Dr. Abramson explains, hospitalists’ “motivations are their professional pride, their training and their relationships within the hospital with their colleagues, nursing staff and hospital” “but not, for the most part, their relationships with their patient.
While hospitalists’ “hearts are in the right place,” he adds, their relationships with patients are “superficial.” Histories tend to not be so thorough, relationship-building and counseling take longer, and readmissions are more frequent. When he admits his own patients, “I am extremely motivated not to have my patients bounce back, partly because of my relationship with them,” says Dr. Abramson. When he admits another primary doctor’s patient as a hospitalist, “I don’t have that same sense of ownership.”
While that may well be the case, most people agree that the majority of primary care physicians don’t have the time “let alone the financial incentive “to come back to the hospital, even as a consultant. As a result, both hospitalists and outpatient physicians are looking for other ways to narrow the practice gap.
A new model
The proposal that appeared in NEJM rekindled hospital medicine’s oldest debate. Coauthored by both a primary care physician and a hospitalist from Boston’s Massachusetts General Hospital, the article proposed a “collaborative patient care model” in which the primary care physician would join the hospitalist as a consultant.
The authors suggested that primary care doctors visit hospitalized patients on the day of admission “to provide support and counseling to them and their families and consultation to the hospitalist team.” The outpatient doctor would write a “succinct consultation note” for the attending hospitalist. The goals of the collaboration would be to “reduce hospitalist workload while increasing personalization of care.”
According to the proposal, primary care doctors should then be available on an as-needed basis before returning to the hospital just before discharge “to consult on the design of a coordinated post-hospital program.” To pay for this extra work, the authors called for a new set of evaluation and management codes to reimburse collaborative care. They also discussed ways to make better use of information technologies to improve communication and facilitate “virtual visits,” as well as how to adjust workflow on both sides to make in-person consults feasible.
Daniel P. Hunt, MD, one of the coauthors, is a hospitalist who directs the inpatient clinician educator service in Mass General’s department of medicine. He says that some of the thinking behind the article grew out of a small, ongoing experiment at the hospital.
In that experiment, a large outpatient practice referred patients to the hospitalist service only after the hospitalists agreed to communicate daily with the primary care doctors. While most of that communication happened by e-mail, occasional in-person visits have turned out to be invaluable, especially when the primary care doctor and the hospitalist can see the patient together.
Dr. Hunt offers this example: A patient in his 80s and his family are considering an aortic valve replacement. “You are trying to decide if the patient can tolerate it, if there is family support and what they have done coming into this illness,” he says. “The PCP can be extremely important in that conversation beyond comforting the family.” The same is true, Dr. Hunt adds, with discussions around end-of-life care decisions.
“De novo” hospitalists
To encourage this type of social or continuity visit, the medical group pays the primary care physicians affiliated with Mass General a stipend “a small amount that neither covers costs nor has adequately served as an incentive, says Dr. Hunt. At Mass General, just like nearly everywhere else, primary care visits to inpatients being cared for by hospitalists rarely happen, a situation few think will change. That’s particularly the case, now that a growing number of physicians consider separate ambulatory and hospital spheres of practice normal.
At Detroit’s Henry Ford Medical Group, for instance, 80% of hospitalists are what hospital medicine division head Peter Y. Watson, MD, characterizes as “de novo”: They have not previously practiced in a traditional inpatient-outpatient medicine practice and therefore “don’t have the staff experience of a pure outpatient relationship.”
“This is not to say that de novo hospitalists don’t understand the importance of the continuity issue,” Dr. Watson says, “but I think their connection with the patient may be a little different.”
And with the exception of “greatest generation” patients who tend to stay loyal to their outpatient provider, many patients are content with the idea of hospitalists treating them in the hospital “and even seek hospitalists out once they understand the concept, he adds. All patients, however, “have expectations that physicians are talking to each other, and we probably don’t talk as much as we should.”
Consider what happened recently at suburban Cincinnati’s Mercy Health’s Fairfield Hospital when a primary care physician, whose patient had been on the hospitalist service, bumped into the patient’s family in the community and asked about the patient, unaware that the patient had died a few days earlier. The hospitalists there now telephone primary care physicians when patients die or suffer a major setback, explains hospitalist Laurie Bankston, MD.
“The family was upset, and understandably so,” says Dr. Bankston, “and so was the primary care doctor.” The patient’s information had generated an automatic message to the primary care doctor’s electronic medical record, “but it was in the inbox with a thousand other things, with no way to flag that e-mail as a priority.”
Calling every primary care physician at admission and before discharge “might not be a bad idea,” Dr. Bankston muses. “Could we do it?” She doubts it. Would patients benefit from their primary care physician making the effort to reach out to them? Some probably would. But given the economics and pace of both inpatient and outpatient practice, neither phone calls nor in-person visits seem realistic to her.
Even compared to just a few years ago, “we very rarely see any primary physicians coming to the hospital any more, even for social visits,” Dr. Bankston points out. “It’s evolved that they just don’t come.”
Too many cooks?
Ironically, widespread adoption of electronic medical records may have accelerated that evolution and created a greater “not narrower “divide. In the past, many hospitalist programs had policies that mandated personally contacting primary doctors on admission and sometimes discharge. But unfortunately, EMRs replaced some of the personal calling process, and Dr. Watson says he can “count on one hand” the number of calls he has gotten directly from primary care physicians in response.
Concerned about this dwindling physician-to-physician communication, the Henry Ford Medical Group issued iPhones to all its members, preloaded with phone and e-mail directories of all 1,300 group members. Those directories are updated every week. The expectation is that all physicians will carry the phones with them at all times and not turn them off. “It has definitely removed one of the barriers,” says Dr. Watson. “It is now tremendously easy to contact people within my own medical group, which accounts for about 75% of my patients.”
He recently used that phone at the bedside to set up a FaceTime session between a hospitalized patient and her primary care physician. “She was about to go to surgery and was more nervous than truly sick. She needed reassurance, so I called the doctor, asked if it was OK to FaceTime and then gave her the phone.” Later that evening, he shot the primary doctor an email saying the patient was doing better. “This hasn’t happened that often, but I think it could.”
Hospitalists also report that they sometimes run across a primary care physician who makes a practice of calling his or her patients when they are in the hospital. Those doctors then make a follow-up call to the hospitalist only if there’s some concern like a subtle mental status change. Such occasional calls, hospitalists say, can bring a lot of insight.
But in Fredericksburg, Va., hospitalist Kyle Compton, MD, hears only rarely from his patients’ primary care doctors “and he doesn’t think that’s a problem. In fact, the NEJM article and ensuing debate struck him “as pie-in-the-sky to think we could invite more people to the party and end up with less cost and better care.” His personal experience with the few primary doctors who have made social visits has, unfortunately, been less than optimal, becoming a case of “too many cooks” rather than two heads being better than one.
“We have very clear data that when the number of consultants goes up, so does your length of stay and complications,” Dr. Compton says. “When you get to the point where you have three or four consultants on a case, it’s nearly impossible to discharge a patient.”
A lost language
Further, Dr. Compton “who has been practicing for three years and is part of the new generation of doctors for whom the inpatient-outpatient split is normal ” characterizes his experience with concierge-practice physicians making social visits to the hospital as more “intrusive” than helpful. “They would want to call three and four times a day and take up an hour, getting results to relay to family members,” he notes. “They were trying to go above and beyond for their patients. But when you are the hospitalist trying to see 20 patients a day, you don’t have an hour to spend.”
His eight-hospitalist group at Spotsylvania Regional Medical Center is now exploring one innovation he hopes may help bridge the divide: a post-discharge clinic. It at least would allow the hospitalists and primary care physicians to work together to build better discharges that would result in fewer bouncebacks.
According to Bradley E. Flansbaum, DO, MPH, a long-time hospitalist at New York’s Lenox Hill Hospital and a member of the Society of Hospital Medicine’s public policy committee, the idea of inpatient-outpatient continuity in the form of one doctor is “just like a rotary phone or VHS.” Physicians are now “coming of age in a system where doctors don’t do it all. It’s almost like you would have to introduce a foreign language that has been lost, even though it was spoken up until not too long ago.”
“It’s one thing to say, ‘We need to do this, and let’s pay the doctors for their time,’ ” Dr. Flansbaum says. “But there is no money. It’s not going to happen.”
Targeting high-risk patients
A better alternative, as Dr. Flansbaum sees it, may be to accept the inpatient-outpatient divide for most patients and continue to improve transitions of care.
He points to an ongoing research project now being conducted by David O. Meltzer, MD, PhD, chief of the hospital medicine section at the University of Chicago. As described in the May 2014 issue of Health Affairs, Dr. Meltzer is testing the use of what he calls “comprehensive care physicians,” doctors who provide both inpatient and clinic care, but only to a small subset of complex, high-risk patients. For such patients, the hybrid model would combine the advantages of hospitalists with that of primary care physicians, complementing the use of traditional hospitalists for most inpatients.
Dr. Flansbaum also wonders if some of this current discussion doesn’t relate more to primary care physicians’ feelings of dissatisfaction with their practice “”confined to an office, absent any inpatient care or exposure to the hospital and mixing with colleagues” ” than to the quality of inpatient care. “Whether spending 5% of your time in the hospital is good for patient care, I don’t know,” he says. “But it might be good for primary care doctors.”
On the other hand, he points out, not many primary care doctors are banging on hospital doors, demanding more access. “I don’t think you’ll see many doctors do this,” even if a way to pay them were found, Dr. Flansbaum says. Instead, this proposal may be “a solution to a problem that doesn’t want to get solved.”
Deborah Gesensway is a freelance writer who covers U.S health care from Toronto.