Paging Dr. Slack!
Last night I had a patient with a bowel obstruction and abdominal pain. He was sent for an outpatient x-ray, and subsequently to the ER, from the office of a gastroenterologist, who had recently performed both upper and lower endoscopy on the patient. The GI doc, new to the area, doesn’t admit. (I never really understood the rationale for that, but anyway…) He told me he didn’t know the procedure for admissions, or who the patient’s primary care doctor was. Fair enough.
The patient informed me that he had been accepted into the practice of one of the local FP’s. The paperwork was complete; all he needed was a first appointment. Easy enough, right?
Well, the doctor who would be his primary was actually on call. I contacted him.
Me: ‘This patient has paperwork in place to see you. Do you want to admit him?’
Him: ‘No, if I haven’t laid eyes on him, he isn’t mine yet. Better admit him to the hospitalist.’
Me: ‘But, he’ll be yours when he is discharged.’
Him: ‘Right. But I haven’t seen him.’
(Apparently the ER has a problem with invisibility).
Me: ‘Well, the hospitalist will get paid for seeing him, not you!’
Him: ‘Yep, that’s fine.’
End of bizarre conversation.
The hospitalist admitted the patient.
Caveat: the primary care doctor is now in a practice owned by the hospital (as is the hospitalist). And apparently, the primary care doctor isn’t interested in incentives for caring for more patients. So this isn’t an overhead issue, where he’d rather avoid the hospital. He just wanted, as far as I can see, to avoid seeing the patient. Never mind the excellent continuity it would have provided. Never mind that he was not a difficult patient, an annoying patient or a soft admission.
Primary care will solve all our woes? Not at this rate, it won’t.
Edwin
This is one of the reasons we needed “7 ways to stay calm in the ED” for Grand Rounds!
As a family physician who recently stopped providing inpatient care, and started using a hospitalist I have seen both sides of the “admit your own vs. use the hospitalist” scenerio. From a what’s the best patient care it is close. I do think the hospitalist has advantages I cannot match for care in the hospital, 24 hour in house availability, much more current experience with the day to day workings of the hospital, etc. The problems stem from the difficulty of getting timely coordination of care info to the primary physician. I routinely see the patient in follow-up before a discharge summary is available, often without even a discharge diagnosis or recommendation for follow up needs. This offsets any advantages of the added inpatient expertise. It really boils down to what our current system values. I can earn 4-5x as much per hour in the office as I can per hour spent on inpatient care. Add this to a better lifestyle without calls all night about inpatient issues, getting home earlier, leaving home for work later, and it is a tough sell to primary physicians to continue to fight the tide and still see inpatients. I agree the doc in question was a slacker. See your inpatients or don’t, but don’t pick and choose like this guy did. This said your comment about the need for more primary care docs is a cheap shot and off topic. We need more primary care outpatient physicians whether they care for inpatients or use hospitalists.
Dr. Pullen, I agree with the need for more primary care! My point is this: if we have more primary care, that primary care has to be accessible. And by that, I mean evening hours, weekend hours, etc. We in the ED are always accused of being the most expensive care. Whether that’s true or not, patients seek care when they need it. And many of the patients I see have called their primary care doc, who was too busy, too late in the day or offered them appointments next week. Then, there’s the ‘I think you may need some tests, better just go to the ER.’ And on the admission side, I’ll have patients from the primary care doc who are sent to the ER, after their doc sees them, so that I can ‘look over them and stabilize’ before sending them to the ICU. What? You just saw them, and they’re going to the ICU, but I need to see them too?’ That’s a lack of confidence and a fear of litigation. Some of our primary care docs who elect not to admit will send their patient for admission, without ever talking with the hospitalist. They just let us figure it out, even though they knew the patient needed admission.
You’re right, you can make more in the office, and I understand that. But 1) they should make continuity arrangements with the hospitalist; and 2) if they do admit (like the doc I wrote about), they should do it. I suspect the problem is that he is a hospital employee and doesn’t need his productivity bonus.
So, I didn’t mean to make a cheap shot, but the point remains. If you want to be the solution, you have to act like doctors for the patients who will be paying you!
Thanks for writing!
Edwin
I hate the daily battle for the unassigned patients at my facility. The hospitalists want to do as little as possible as they say they don’t get an incentive per admission. The residents of course make the same if they admit 0 or 30. So you call the resident service, and they say that back in 1993 the patient went to doctor so and so, and the hospitalist admits for them. The patient states he fired that doctor in 1994. The hospitalist then states they don’t admit that patient because he goes back to unassigned. Then unassigned is capped. Then it is shift change. I wish that I could average only two calls per admission.