Any hospital stay, especially an unexpected one, can be a time of great stress. It’s bad enough that you are not feeling well and are stuck in this strange place rather than at home, where you are comfortable. On top of that is the vulnerability you or your family experience by not being sure of the outcome of this episode. Unfamiliarity with the health care staff, who are (hopefully) attending to your needs, creates another layer of anxiety. It’s confusing to even know “who’s who.” Is this person entering the room a PA? Intern? Resident? Nurse? Doctor? Mickey Mouse? (If you see Mickey Mouse, you may need an adjustment to your medications.) Even when you feel you are receiving excellent treatment, it is obvious you are not the only patient your doctor or nurse needs to tend to, and understaffing can be a problem.
And, by the way, there is one more thing that may add to your discomfort: You won’t be seeing your own regular internist or GP any more. Even if your internist, whom you trust and with whom you have a relationship, has hospital “privileges,” he or she will not be examining you or visiting while you are hospitalized. Oh, where is Marcus Welby when we need him?
The beloved, all-knowing fictional TV physician is long gone, along with his show. It’s not that your doctor doesn’t care about you. He or she does. It’s just that our health care system has been evolving for many years, and the changes can be disconcerting. The current model, which has become more evident recently, is similar to what is done in other parts of the world, including Canada, European countries, and Israel. Namely, once you are admitted to the hospital, you come under the care of the doctors employed by the hospital, called “hospitalists,” and your primary care physician can no longer officially be involved in the management of your case until after your discharge.
What’s Good About It?
There are certain advantages to this system. The hospitalists and their teams of medical staff in the hospital are right there 24/7. They can see the patient several times a day, run tests, get the results immediately, and decide on treatment. This usually allows for a shorter hospital stay, which can be an advantage to the patient as well as to the hospital. Many patients are quite satisfied with the care they receive in this way. Shmuel* was so thrilled with his experience under a hospitalist’s care that he wrote an unsolicited letter to Sinai praising his doctor to make sure that he was recognized for his exceptional skill and caring attitude.
I also contacted two friends who live in Europe to ask if they were satisfied with this model of health care, because they have been living under a similar system for many years. Henye Meyer, an American writer who has lived in Manchester, England, for nearly 40 years, has only words of praise for the excellent care she received during her two hospitalizations of four months and one month, respectively, during which she had surgeries, rehab, and chemo.
She writes, “The GP, the first point of contact, has the medical knowledge to know which sort of specialist to refer you to. He is updated regularly by the doctors whose care you’re under at the hospital.
“Most of the staff, from doctors at all levels through nurses and even support workers, are dedicated people committed to their professions and ready to bond with patients they may never see again. When I went back to one ward to say hello 10 months after I’d left, we had a real huggy session! I found that nearly all the hospital doctors handle their patients well and follow up with real personal interest in their patients’ progress.
“To be honest, even though I could also complain about holes in the NHS [England’s National Health System], I’ve had such outstanding care from everyone on every level that I won’t say a word against it, just as (lehavdil) Moshe Rabeinu couldn’t strike the Nile for the first makka because it had sheltered him.” Mrs. Meyer recently read a statistic that indicated complaints about the NHS have actually gone down in recent years.
Rivky T, who lives in Belgium, has also been mostly satisfied with her hospital experiences. She feels that the bedside manner of any doctor simply depends on their personality, and it makes no difference whether they are private physicians or hospital doctors. In addition, in Belgium, your physician will be kept informed throughout your hospital stay, receiving all test results and updates. From what she has heard, she feels the system in Belgium is much better than that in the U.K. or the U.S., particularly since it is inexpensive and one receives quality care.
It’s Not All Rosy
Because we Americans are used to the old system, or perhaps because kinks in the new system have not yet been worked out, both community doctors and their patients are sensitive to what feels like a break in the doctor-patient relationship. It can be a jarring experience when patients are thrust under the care of a total stranger who knows nothing about them or their previous history. Dr. Menachem Cooper, a long-time physician in Baltimore’s Jewish community, says, “Doctors, especially primary care doctors, have always prided themselves in getting to know their patients and their families and what makes the patient tick. If you can’t follow your patient into the hospital, you lose that part of the loop, and the loop falls apart.”
It is not only in Baltimore that these concerns are felt but all over the country. Richard Gunderman, M.D., Ph.D., writing recently in The New England Journal of Medicine, says “Increasing reliance on hospitalists entails a number of risks and costs for everyone involved in the health care system – most critically, for the patients that system is meant to serve. As the number of physicians caring for a patient increases, the depth of the relationship between patient and physician tends to diminish – a phenomenon of particular concern to those who regard the patient–physician relationship as the core of good medical care.
“The true core of good medicine is not an institution but a relationship — a relationship between two human beings. And the better those two human beings know one another, the greater the potential that their relationship will prove effective and fulfilling for both.”
Dr. Julian Jakobovits, another long-time community physician, concurs and adds, “For our community, in particular, not having your own doctor is very disorientating for a patient at the time they need it the most, especially with complicated cases. For example, if a patient is in Intensive Care, oftentimes it is not only medical decisions but halachic decisions that need to be made.”
In such cases, our community doctors, particularly ones with whom we share a culture, can be much more sensitive to these issues. Dr. Jakobovits said that he has been in the beginnings of some discussions with the hospital about what community doctors can do to “hold the hands of patients” while they are there. He says the hospital recognizes that there is a difficulty, but there is no solution at this point.
It Comes Down to Money
So why are community doctors no longer visiting the hospitals when their patients have been admitted, including Sinai? Dr. Cooper says there are many reasons for this, including financial and political ones.
When a patient is admitted to the hospital, the fee, determined by the Health Services Cost Review Commission (HSCRC) that the hospital can bill for is not based on the length of stay. It is based on factors such as age and diagnosis. This makes it more cost effective to get the patient in and out of the hospital as quickly as possible. The less amount of time the patient is in the hospital, the greater chance for profit on the hospital’s part. The hospitalist, along with other medical personnel, is a salaried employee of the hospital. When the hospitalist is in charge of the patient, the hospital receives the payment.
Disincentives to Care
Under the old system, community doctors visited patients during their hospitalization, and the doctor’s practice would receive the fees. As Dr. Jakobovits explained, under that system, he could see his patients once a day, order any necessary tests, and be in touch with the hospital team, which included interns, residents, and physician assistants (PAs). He was able to check on his patients and be kept in the loop. The hospital no longer provides this infrastructure. “Sinai does not tell doctors they cannot come in,” said Dr. Jakobovits. “They are welcome. But for that to work, [community doctors] need to have that team of people who will work with them. The hospital staff members are no longer answerable to private doctors. They can communicate, of course, but there is no official hierarchy. This is tantamount to not having privileges.”
Without an infrastructure where he would be directing his patient’s care, he cannot manage a case. If he did visit, he would have to defer to the hospitalist, who writes the orders and guides the case. Therefore, Dr. Jakobovits rarely goes to the hospital any more, other than for social visits. As a matter of fact, if he did want to officially visit a patient, he would not be able to bill for his services. Since the patient is under the care of a hospitalist, that would be considered double billing.
Dr. Cooper sometimes tries to follow-up with a hospitalized patient from afar, and may take phone calls from the patient’s family during his stay even though he does not get reimbursed for it. But when he does not follow up, he needs to spend a lot of extra time after the patient’s discharge to see what changes are made and whether he thinks the changes were appropriate to ensure continuity of care.
According to Dr. Jakobovits, “The degree of communication with private doctors is less than perfect. There is an opportunity for poor or no communication when a patient enters or leaves a hospital.” The hospitalist does not know the patient personally or his past history. A major concern of doctors is not only that they have been left out of the loop but that it can take a lot of extra time to get back in the loop. Both Dr. Jakobovits and Dr. Cooper have reported problems with receiving discharge summaries. Dr. Jakobovits says, “Sometimes I get a call, most times a written report, but sometimes I get nothing.”
Dr. Gunderman writes, “Practically speaking, increasing the number of physicians involved in a patient’s care creates opportunities for miscommunication and dis-coordination, particularly at admission and discharge. Gaps between community physicians and hospitalists may result in failures to follow up on test results and treatment recommendations.”
Dr. Cooper says that upon a patient’s discharge, the hospital often expects him to get on the computer and download pages and pages of notes. Doctors with hospital privileges can get into the Sinai and Lifebridge computer systems to read the EMRs (electronic medical records). However, this takes a long time to go through and is very time consuming for him or his staff. He used to get an automatic discharge summary, whether the patient was under his services or someone else’s. “If you have 10 patients you have to do that for, that’s two hours worth of work in order to get the information that a simple fax or mailed record could have provided.”
According to Dr. Cooper, “The EMRs are not necessarily helping patients.” Although they are meant to facilitate the transfer of knowledge about your treatment and condition from one health care professional to another and from one shift to another, “They not easy to read through. There’s a lot of redundant information, even false or inappropriate information, and it has not been the panacea that everyone said it would be. It’s a data grab for insurance companies and the government to get a lot of information, but it hasn’t really helped the patients.”
Dr. Cooper said community doctors recently had a meeting with Sinai administration to discuss how the hospitalists at Sinai were not very communicative with the private doctors, who had problems getting the information they needed once a patient was discharged. (He feels this problem exists in other hospitals as well.) Dr. Cooper reports that Sinai’s administration is working on this problem. He thinks that it actually has improved in the past two or three weeks. They are also trying to come up with a way to reimburse doctors for seeing a patient within a couple of days of his release from hospital, so that the doctors can get themselves back in the loop.
Specialty Care Is Also Different
From what Mrs. Meyer and Mrs. T wrote, it seems that the U.S. hospitalist system might be able to learn from what goes on in Europe, where, as they wrote, the hospital doctors regularly updated the GPs. We apparently do not yet have a good infrastructure for that. As Dr. Cooper told me, at this point, even if and when a hospital doctor contacts him to discuss a patient, it takes valuable time out of his tremendously busy day. With patients in the waiting room and things going on in the office, such as phone calls with other doctors or with pharmacies, “It’s not so simple to be ready on the spot. Having better contact with his patients’ hospitalists during the day may be the right thing to do, but it is currently not the realistic thing to do.”
According to Dr. Land,* a specialist I spoke with, “On paper, the hospitalist system is excellent. However, there is a lack of empathy on the part of hospital doctors, who do not know the patients well and often cannot relate to them culturally.”
He says even specialists with privileges (who are allowed to manage their hospitalized patients’ care) are finding it more difficult to admit patients under their own name and are pushed to admit patients to the care of a hospitalist. “The hospital always tries to get me to admit my patients to a hospitalist. They try as much as possible to push outside specialists away. It’s not that they can refuse you, but they discourage you by putting up a lot of red tape. Some specialists won’t bother trying to admit patients to themselves anymore, saying it is just not worth the hassle.”
Dr. Land blames this on monetary concerns as the hospital is then able to make money. If he admits a patient under his own care, his practice is the one that gets to bill the insurance company. Dr. Land feels that “Today we have better medications and treatment, but the quality of care is much lower.”
Dr. Cooper points out that the new system may be creating several unintended consequences. One is training. “Primary care doctors are going to be less and less common because most of their training to be community doctors was done in the hospital setting,” he says. “They spent three years in the hospital and one day a week in a clinic, which mirrors the outpatient setting. A lot of knowledge and information comes from that system. However, now they are going to try to focus on making it more of an outpatient-type training.” Dr. Cooper believes that would-be doctors in this system will miss out on important training.
They will be less comfortable with specialty care, for one thing. “A lot of issues that we take care of in the office are things we had exposure to day in and day out in the hospital.” Now that he does not go to the hospital anymore, Dr. Cooper feels he is losing that additional training in that setting. “I often felt that being in the hospital orbit and seeing patients interacting with the specialists and all the other doctors there made me keep my medical knowledge and understanding much more up to snuff.”
Dr. Gunderman discusses this in his article: “The physician’s lounge, once an important site of knowledge sharing and professional collegiality, may become depopulated. Exclusively inpatient and outpatient physicians see each other less frequently, and medical students and residents have fewer role models who provide comprehensive care. In effect, the mounting walls of the hospital constitute an increasingly impermeable barrier between the members of the profession.”
Dr. Cooper feels that, down the line, most of the primary care providers will be nurse practitioners and physician assistants with fewer and fewer doctors doing it. He says there’s a big push now to have doctors go into primary care, but he does not think that it will happen.
Because the level of training may be different in the future, says Dr. Cooper, if someone has something seriously wrong, he or she will need to go to a specialist – and hope that their primary care doctor/PA or nurse practitioner will be able to allow them to go to do that. “This will fragment care even more than it is already.”
Another unintended consequence, says Dr. Cooper, is that “community physicians and community hospitals, like Sinai, feed each other, meaning that they help each other. The hospital gives certain things to the physician, like continuing medical education and having physicians on hospital boards where they could help with medical executive decisions. There was a symbiotic relationship between hospitals and community physicians. That is gone. That means that every physician out there will not have allegiance to a hospital unless he is a hospital employee.”
Dr. Cooper told me that he has been approached by hospitals to become one of their employees while keeping his practice. He is not interested, at this stage of his career, in doing that. Although they guarantee an increase in salary for several years to doctors who come on board, the hospital is the boss. The doctor runs day to day operations, but the hospital takes over the billing, makes major decisions, and enforces certain requirements, such as making sure that EMRs are done. Dr. Cooper said hospitals don’t really buy practices anymore, but prefer this incentive system, where, after several years, they basically own the practice anyway. The reason they can guarantee an increased income is because hospitals are allowed to bill more than physicians. Once a physician works for a hospital, his office becomes a hospital site and can bill accordingly. Of course, this does not save the insurance companies any money, so they are not so thrilled with this model.
While no one expects our health care system to return to the way it was 20 years ago (and it’s never been perfect), it is apparent that more adjustments will need to be made so that the current system is better than simply “good on paper.”
* a pseudonym