Ask the doctor: Where are the hospital visits?

Apr. 15, 2014 @ 11:00 PM

Doc: Why doesn’t my physician see me anymore when I’m in the hospital?

A: It usually isn’t because your physician doesn’t want to, rather, it has more to do with the mechanisms of actually caring for a patient in a hospital becoming so complex.

A trend in medicine began in the mid-1990s for some physicians to only work in a hospital, caring for patients admitted for treatment, whether it be a regular floor room or ICU, and then discharging the patient home to see their family physician for follow up. It began as a service for physicians in large groups who would have to drive long distances to a hospital, often spending more time on the road than actually seeing patients.

The New England Journal of Medicine then coined the word “hospitalist” in 1996. It has become a commonly used phrase now for the physicians who only work in a hospital caring for admitted patients. These are usually highly-skilled physicians for whom the sickest and most critical patients are as routine as the sun coming up in the morning. The studies have shown they provide excellent care in most cases.

The trend has rapidly increased with momentum as there are now residencies (the three to six years of training a physician undergo after medical school) which focus on training physicians for this roll and groups of physicians who work to staff several hospitals in a region as their sole focus.

At first glance, quite a few patients may think that their physician is simply now taking the easy road and trying to coast along toward retirement not wanting to be with their patients in a hospital when they are the sickest. Nothing could be further from the truth. The fact is it takes nearly three times as long to deal with the process of managing a patient’s care than it does for actually diagnosing and deciding what to do for that patient.

This is true of all hospitals, not just a select few, because of the government, credentialing and insurance regulations and requirements.

All admissions to a hospital are reviewed for appropriateness simply because an unnecessary admission, in the eyes of the payer, will not be reimbursed. This means it is critical for the nurses, pharmacists, physical therapists, social workers, discharge coordinators, dietitians and physicians to document, document, document. Document everything because someone — sitting hundreds of miles away — will review the admission and one simple thing can cause the entire admission to be denied meaning no payment for the hospital or physician. This is the primary reason a discharge takes over four hours in most cases.

I clearly remember sitting next to a talented hospitalist in the doctors’ dictation room as she was on the phone to “case review” a physician in Minneapolis trying to convince him the patient actually needed to be in the hospital. She had been on the phone for nearly 40 minutes to no avail, and he was going to deny the admission in spite of the fact that she, skilled physician looking at the patient, was adamant the patient was sick.

At that moment, the nurse ran in the room informing the hospitalist that the patient was “coding,” meaning had gone in to cardiac arrest. She slammed the phone down and ran to care for the patient.

If the hospitalist had been with the patient, instead of trying to convince a physician hundreds of miles away that the patient was sick, it is arguable that the patient would not have coded.

The requirement of electronic medical records is a reason some physicians have left hospitals, and even more are leaving the profession altogether. Anyone who has ever purchased a new computer, or upgraded, or obtained a new word processing software, knows how frustrating it can be to learn. Imagine being responsible for a very sick patient and the only way to enter orders is through a program which may, or may not, have been well designed by people who actually use it.

Case review is also time consuming. Even months after an admission has been completed a physician may have to spend time clarifying details of an admission to satisfy regulations and requirements in place by the payers of healthcare.

Many physicians will still make “social” rounds to see their patients because of the bond they feel with those they see in the office.

The realities of time and complexities of satisfying regulations have created this hospitalist trend. It is the further “industrialization of medicine” and in the hearts of many physicians, including my own, who try to be old-school. It is a sad, but understandable, reality.