Hospitalists, specialists, primary-care physicians: It's game time!

From kickoff to halftime, there is no greater example of the importance of teamwork than the annual Super Bowl. The Ravens proved that tonight.

Although less popular, more crucial than the outcome of any football game is the responsibility to coordinate, communicate, and improve the well-being of our most vulnerable patients. Recently, I received a phone call from a patient's daughter. Her mother, "Mrs Smith," was hospitalized in another town 40 miles away with GI bleeding, on warfarin with chronic atrial fibrillation. The daughter was greatly distressed because this wasn't just a "little bleeding"; it was major league BRBPR, "doctor speak" for "bright red blood per rectum." Having just gushed 50% of her blood volume into the toilet bowel, her hemoglobin dropped to a dangerous level of 6.

She had received multiple units of packed red cells but was holding her own. That was on a Monday. The worried voice at the other end of the line belonged to someone attempting to quarterback her mom's medical team. She was trying desperately to avoid a fumble deep into a game she had obviously never played. She simply asked, "Dr Walton-Shirley, does mom have to stay on this Coumadin?"

I replied, "Right now, although her risk of stroke is very high off blood thinner, I'm sure they are holding her Coumadin. If we are lucky and they can fix what's bleeding, we might be able to resume it. Just have the hospitalist call me. I'm at the office all day. I have her chart right here in my hand. I'm glad to help." The nice daughter thanked me profusely for the conversation and hung up.

Wednesday, my secretary came to the exam room door. "Someone needs to speak to you about Mrs Smith," she said, chart in hand again. "Sure," I said, apologetically to the waiting patient in my exam room. "Hello, I'm a nurse taking care of Mrs Smith," the cheery voice at the other end of the line proclaimed. "And the doctors here need to know if she can stop her blood thinner." Patiently, I replied, "I spoke to her daughter yesterday and explained that she's elderly and has atrial fibrillation, a pacer, and a high CHA₂DS₂-VASc score, but certainly she must stop the warfarin for now. The salient point is that someone needs to locate the bleeding source if possible. Please ask the hospitalist to call me," I requested. "Here is my cell number in case it gets late," I added. The polite nurse thanked me and hung up the phone.

Thursday, I was examining a patient when I saw him look toward the door over my shoulder. With the stethoscope still on his chest, I turned to see my secretary mouth that I was needed on the phone. I apologized and stepped outside. "Hello Dr Shirley, I'm a nurse taking care of Mrs Smith, and the hospitalists need to know if she can stop her blood thinner."

"Okay," I said. "I know this is not your fault, but in our medical system, this extreme lack of communication is exactly why patients die."

"I know", she said in total agreement.

"I really appreciate your phone call," I added, "But this is a conversation that needs to happen between the attending physician and the patient's long-term providers. Can you please have her physician call me?" I asked.

"Yes, I most certainly will," she replied.

The day passed and I heard nothing.

I awoke Friday morning with that thought that as soon as I could see the first few patients of the day, I would page Mrs Smith's hospitalist. At around 3 pm, just as I was standing in front of my secretary and the words were literally coming out of my mouth to page the in-patient provider, another secretary rushed up to me and said, "They are frantic for records. Mrs Smith just coded, was shocked, moved to the ICU, and again arrested in Vfib. She's on the vent."

I don't care how much money the system makes or saves or whose feelings are hurt. The absolute worst thing that could ever happen to an in-patient is to change quarterbacks every day. Although I may not have had information that could have prevented this turn of events, they would have never heard it if I did. The best thing that could ever happen to the legions of patients whose only option is to bow to the current march of hospitalists across our country is to create a hybrid program that actually works in favor of the patient. Relative value unit–minded CEOs need to pay primary-care physicians well to round daily, give them a schedule that allows enough time to get to the office, and then have nighttime and weekend coverage provided by hospitalists. This coordinated effort would score touchdown after touchdown for the patient who is currently at the mercy of a system driven by the opposing team's "quarterback sneak equivalent" known as the 23-hour admit. For those patients who get to stay long enough to actually receive the duration of therapy they need, we owe them our best plays. Right now, it seems no one's holding the playbook, or it seems that in the busy mix of a 12-hour shift, no one really has the time to care.

It's Sunday evening. The hospitalist quarterback is in place. The coach on the sideline communicates through the earpiece the result of the patient's last office visit and tests. The teammates—consisting of nurses, techs, and ward clerks—line up for the field goal. The whistle blows and the team goes into action as the patient is passed back to the placeholder. The specialist kicker runs forward, leaps into the air, sending the patient into orbit. The patient is hurled through the goalposts for a successful completion of an in-patient admission.

Congratulations, Ravens. Wish you could coordinate every in-patient hospital admission for every patient struggling in our current healthcare delivery system. You knew it was game time and through perseverance, communication, and determination, despite momentum-busting power surges and blackouts, you delivered.

So should every in-patient provider in America.

Your comments

	Hospitalists, specialists, primary-care physicians: It's game time!
	# 1 of 28	February 4, 2013 04:41 (EST)
	SAMEER BANSILAL	Communication versus common sense While I am in complete agreement on the overall message of your post, I find it appalling that a medical team dragged the issue for 5 days and needed expert guidance to stop a blood thinner on a patient with a major league bleed and a hemoglobin of 6. Isn't that plain old common sense? Author's disclosure (Feb 4, 2013) I have no relevant disclosures to make in connection with this topic.
	# 2 of 28	February 4, 2013 09:37 (EST)
	Melissa Walton-Shirley	Sameer I don't think they kept giving the blood thinner. (At least I hope not). It was just frustrating that every day, a different hospitalist would round on the patient and ask the same question-which I would answer through a 2nd party (on three occasions) and never was able to speak to the team that was providing primary care to the patient. I will note that when the patient coded, a cardiologist was immediately called and was gracious enough to contact me for a discussion within a couple of hours. To this date, none of the team has contacted me. I have provided cardiovascular care to this patient for over twenty years (even implanted a pacer in him in the nineteen nineties) Thanks for your post Sameer. Author's disclosure (Feb 4, 2013) I have no relevant disclosures to make in connection with this topic.
	# 3 of 28	February 5, 2013 01:26 (EST)
	Nabil Kamas	Clinical pharmacist? Do they not have a clinical pharmacist as part of their team? I am sure he/she would have given a useful insight on stopping the anticoagulant and when best to resume it. We rely on our clinical pharmacists to help us make any decision regarding drug therapy. They have helped us optimize therapy and prevent many medication errors, drug-drug interactions, monitor drug levels... But I fully agree that they should communicate with you. I totally agree with your concerns. Author's disclosure (Feb 5, 2013) I have no relevant disclosures to make in connection with this topic.
	# 4 of 28	February 5, 2013 08:04 (EST)
	Melissa Walton-Shirley	Nabil I'm not certain about their having a clinical pharmacist but agree they are an integral part of any team, however, if the team is this disorganized, I'm not sure how closely they would listen anyway. I think we need to come back a bit toward some of what has worked to the advantage of the patient and incorporate some of the new conveniences for docs and hospitals and hyrbridize the approach to in-patient care. It's never too early to reform what's not working. Author's disclosure (Feb 4, 2013) I have no relevant disclosures to make in connection with this topic.
	# 5 of 28	February 6, 2013 12:40 (EST)
	william rollefson	Another example of American medicine going in the toilet I would have used stronger language, but this is a polite forum. I absolutely hate the hospitalist system. Not just because of your example, Melissa, but the for the disruption of the patient/physician relationship. We have become a medical community which has gotten so stretched due to the perceived need to see more patients that we have lost sight of the need to provide continuity of care. It is disgusting, IMHO. Author's disclosure (Feb 6, 2013) I would like to eliminate the hospitalist system entirely. While it might function in an academic center, it doesn't work in the community worth a damn.
	# 6 of 28	February 6, 2013 08:49 (EST)
	Timothy  McKeever	The Constant Struggle A very well illustrated example depicting one of the root causes of why our healthcare delivery system lags in outcomes. Every day, I struggle to get our hospitalists to communicate with the physicians who manage patients outside of the hospital setting. What they lose sight of is that those physicians are a wealth of information because they have such a history with the patient. In your example, someone had to have been keeping track of her INR, which has to be checked at least bimonthly. Relaying messages using nurses as the intermediary is a poor method for doctors to communicate, especially in critical situations like you describe. Continuity of care demands timely and direct communication between providers. Author's disclosure (Feb 6, 2013) I have no relevant disclosures to make in connection with this topic.
	# 7 of 28	February 6, 2013 09:15 (EST)
	Melissa Walton-Shirley	Yes I agree Tim. One of the first things I asked was if she was over-anticoagulated. I looked through the history of her INR's and for three months in a perfect 2.0-2.5 level but had not checked in for 6 weeks. I wondered if she had received antibiotics, etc. On the second phone call, I learned she was good on her INR at presentation which goes directly to the question of an absolute need to aggressively search for a cause of bleeding. In this situation,the patient was out of town so her family doc could not round on her or be directly involved. However, with the "wealth of knowledge" you describe in towns all across America, docs are working in their offices while cases like this are ongoing in-hospital and the lack of access to that information is a definite factor in poor outcomes. We've allowed ourselves to be brainwashed that this movement is good for patients. It's good for wallets and CEO bottom lines, our work schedule, family time for health care providers, but little else. I'm for a hybrid model. That WOULD work to the good of all-Yet folks cry foul, try to pretend those of us who do not worship mediocrity "backward", behind the times,disloyal, not a team player, even disruptive and when one stands up for the patient, folks run from that notion like it's leprosy. Well.....at least they do in this present time. When systems become culpable for this practice,like mini-skirts the trend will somewhat reverse more toward a workable middle ground that actually favors the patient. Author's disclosure (Feb 4, 2013) I have no relevant disclosures to make in connection with this topic.
	# 8 of 28	February 6, 2013 09:31 (EST)
	Mark Milunski	Sign of the times Two points. One, we carry more electronic gear on our belts and in our pockets than Batman has in his utility belt yet we can't pick up a phone and talk to each other about important patient care issues. Two, this patient needed a doctor and had none. Disgraceful. Author's disclosure (Feb 6, 2013) I have no relevant disclosures to make in connection with this topic.
	# 9 of 28	February 6, 2013 05:33 (EST)
	Giovanni Gulli	Humbly proud of my (nearly unsustainable) hospitalist system My Country has one of the highest debt-to-GDP ratio in Europe, a very high unemployment rate, has mafia and has (hopefully for a short time left) Berlusconi, but something like what you described would never happens, not even in the most remote hospital, where the patient/hospitalist relationship is strong and continuous, much stronger than the one he/she has with physicians who manage him/her outside of the hospital setting and usually do not care about what is going on during the admission of their patient. Author's disclosure (Feb 6, 2013) I have no relevant disclosures to make in connection with this topic.
	# 10 of 28	February 6, 2013 09:13 (EST)
	Espinoza Andrey	Question Great story that highlights a number of very salient issues moving forward in our new delivery system....however, Melissa....why didnt you call the hospitalist instead of waiting for them to contact you? Author's disclosure (Feb 6, 2013) I have no relevant disclosures to make in connection with this topic.
	# 11 of 28	February 6, 2013 09:38 (EST)
	Melissa Walton-Shirley	Good question Espinoza The patient had been in the hospital for two days before I even received the first phone notification of the patient's admission. I asked that the nurse page the hospitalist and both said they would page them and give them all of my contact numbers including my cell, but on that Friday, I realized this was just going on too long and as I was literally asking my secretary to get on the trail, the patient coded. I'm not certain a conversation would have impacted the outcome but certainly any chance of that was removed by this break down in communication that I find the norm instead of the exception. Author's disclosure (Feb 4, 2013) I have no relevant disclosures to make in connection with this topic.
	# 12 of 28	February 7, 2013 12:14 (EST)
	Ralph Millsaps	But you don't understand the guidelines We must have hosptialists! No one can work more than 80 hrs every two weeks and if we follow the European guidleines no more than 38 hrs/week. If we have physicians work more than this, patients get bad care! Don't you understand how bad the care has been for the last 50 years? We, the government and its associated minions, are making care better. Shift work is the way to go and the new doctors like it so much better! Knowing a patient for 20 years is clearly overrated. If you oppose this methodology you will be reported. (no purple type for sarcasm):) Author's disclosure (Feb 7, 2013) I have no relevant disclosures to make in connection with this topic.
	# 13 of 28	February 8, 2013 02:33 (EST)
	Annie Wong	Transitions of Care Is the current problem role identity or transitions of care? Is the question a continuity of care from the same provider, or communication on continuity of care . Though we are continuously trying to shape our healthcare system to become a multidisciplinary team, we are not achieving INTERdisciplinary teamwork. It is much more convenient to work in compartments and let our ego decide on how to treat the patient. Consulting different disciplinary is so unnecessary and what's more, a phone call from a physician is just too much work to fit into the busy schedule. Really?! Author's disclosure (Feb 8, 2013) I have no relevant disclosures to make in connection with this topic.
	# 14 of 28	February 8, 2013 05:12 (EST)
	william reichert	stopping coumadin why does a hospitalist need to ask a cardiologist if is is ok to stop coumadin in a patient who is bleeding to out half her blood volume?. Please explain.. Author's disclosure (Feb 8, 2013) I have no relevant disclosures to make in connection with this topic.
	# 15 of 28	February 8, 2013 08:17 (EST)
	William Michael	Response to #14 It is called internal medicine - the whole story is nonsense and would have required a phone call at the end of the hospitalization. Swing and a miss Melissa. Author's disclosure (Feb 8, 2013) I have no relevant disclosures to make in connection with this topic.
	# 16 of 28	February 9, 2013 08:37 (EST)
	william reichert	the phone call In my VAST. experience as a hospitalist the odds of actually speaking on the phone to a physician about a shared patient is about the same as my winning the lottery with a single ticket. "She's with a patient, out to lunch, off today, in a meeting....". Not going to happen.Communicating by mail or computer is the best we cn do and it leaves. lot to be desired. uter Author's disclosure (Feb 8, 2013) I have no relevant disclosures to make in connection with this topic.
	# 17 of 28	February 9, 2013 10:15 (EST)
	Melissa Walton-Shirley	William R. I'd have even welcomed a text. Secondly, the entire question wasn't "can we stop warfarin in a bleeding patient", it's "Does the patient need to remain on warfarin?" at discharge. As far as swinging and missing, the important thing is that we continue to go to bat for patients. If the opinion is" it's not worth the effort to make a phone call" in a patient so frail as this, well, that pretty much says it all. Author's disclosure (Feb 4, 2013) I have no relevant disclosures to make in connection with this topic.
	# 18 of 28	February 12, 2013 12:36 (EST)
	Ybor Novotony	Office Dr's vs Hospitialist I had an interesting experience when my wife was admitted to the enmergency room at the hospital. After waiting 8 hrs to be assigned a room -a hospitalist we had not meet or even had a name- finally did it after another 8 hours when nothing seemed to be done , I attamped to get in touch with our internist- impossible but finally I was told he was an "Office" Dr and didn't respond to hospitals, the same response came from her Neuroligist. So we waited for who knows: someone in the hospital to decide what to test and what to do. Much later when I asked the internist about what we should do- we were "fired" Welcome to modern medicine where DRs are not associated with Hospitals and unknown "hospitalist" decide on the basis of the lst 24 hours of tests what to do. YN Author's disclosure (Feb 12, 2013) I have no relevant disclosures to make in connection with this topic.
	# 19 of 28	February 12, 2013 06:16 (EST)
	william reichert	hospitalist delay I am hospitalist .At my hospital we see the patient within 20 minutes of "being notified of a patient in the ER". Usually there is a great pressure to see the patient and get them admitted. So I wonder if the hospitalist was called. Otherwise I agree that your delay sounds bad. The whole idea of the hospitalist is to expedite the care because in the past the "office" internist was ALWAYS delayed in getting to the hospital being tied up in the office. Deciding on what to do based on the tests done in the first 24 hours is the standard of care. I do not understand how this can be considered an issue. Please explain. Author's disclosure (Feb 8, 2013) I have no relevant disclosures to make in connection with this topic.
	# 20 of 28	February 13, 2013 07:12 (EST)
	Melissa Walton-Shirley	In my opinion .......the worst thing that could have ever happened to modern medicine is to create circumstances which take the primary care provider out of the in-patient mix. Case in point: my neighbor's mom became confused. Had a week long hospital stay, subdural hematoma, transfer for a burr hole, back home then back to the primary care office doctor who bounces in and says, "and how are we doing today?" The son said, "You don't have a clue what we've been through do you?" And he didn't. But.....it gets more complicated than just an inconvenience. The ideal model would be a hybrid approach; invite hospitalists to get the ball rolling, have the primary care doctor to come in on the case at the end of the day, or next morning...a blend of convenience and familiarity. I am hopeful that this trend is like bell bottoms-looking back we'll realize just how awful it was for everyone and we'll make a better system. In my opinion, unless the patient is crashing, a well coordinated plan hashed out by the ER doctor and the internist by phone works better than a team who rotates attendings, none of whom know the patient and then has another extender discharge the patient whose never met them either some of the time. It's fraught with pitfalls. Author's disclosure (Feb 4, 2013) I have no relevant disclosures to make in connection with this topic.
	# 21 of 28	February 14, 2013 05:45 (EST)
	Adeleye Erinle	Communication Well said. I am a clinical Pharmacist and all this events are prevent with strong communication network Melissa identified. Author's disclosure (Feb 14, 2013) I have no relevant disclosures to make in connection with this topic.
	# 22 of 28	February 14, 2013 05:47 (EST)
	Adeleye Erinle	Communication Type error. Well said by Mellisa. It comes down to communication. Where I work as clinical pharmacist, this is like sending discovery to mars and waiting for years before conclusion could be made. It's the word communication. Author's disclosure (Feb 14, 2013) I have no relevant disclosures to make in connection with this topic.
	# 23 of 28	February 14, 2013 06:43 (EST)
	vern chichak	ctus i have had the prviledge to be an internis in \canada for the last 30 years and was very concerned about the transition to a CTU- clinical teaching unit in which the continuity of care was affected ie if a patient spent more than 2 weeks on the internal med service it is conceivable that two three differnt internists would be taking over the care via the transfer of care model however in The province i work in we have an excellent electronic system called alberta net csre providing access to all the important info on a patyient available to all mds hospitalist etc province wide as well the team of are hospitailists nurse practioners pharmacists residents etc really provide an excellent model at the point of discharge all patients receive to take to their primary care provider a short dischagre form precceding the formal dictated discharge summary i believe that this has prevented many times the situation you have disussed Author's disclosure (Feb 14, 2013) I have no relevant disclosures to make in connection with this topic.
	# 24 of 28	February 14, 2013 08:51 (EST)
	Ashok Daftary	Sad but true The Annals of Internal Medicine on the 2nd May 2006 published my letter. Unfortunately, my cynicism was justified I paste excerpts below. Thirty years of practice as an internist allow me to make further observations. Academic medicine is the carpenter that fashioned the coffin of internal medicine. Instead of reengineering internal medicine to accommodate change, it cannibalized the discipline by reducing its worth, creating the hospitalist and ambulatory care internist. These were both nails that helped seal the coffin; the former reduced the influence of the internist in the acute care environment, and the latter blurred distinctions between internists and those without medical degrees who practice in ambulatory care settings. Medical subspecialties that are nurtured in the ivory towers of academia have further reduced the stature of the internist. Effective lobbying by their affiliated societies and by commercial manufacturers of the medical devices they use assured them disproportionately higher reimbursement than that of their generalist colleagues. Absent an identity, the internist's only remaining role is thought to be that of provider of ambulatory care to the chronically ill whose medical problems are beyond procedural intervention and lucrative compensation. A continuing decline in professional stature and income, when coupled with deteriorating working conditions, makes the continued existence of internal medicine untenable. I am pessimistic that current political and professional interests will allow significant change to resuscitate internal medicine. Would it then not be opportune to draft an obituary for internal medicine and commission a requiem to its memory? Ashok V. Daftary, MD Sutter Gould Medical Group; Stockton, CA 95210 Author's disclosure (Feb 14, 2013) I have no relevant disclosures to make in connection with this topic.
	# 25 of 28	February 15, 2013 08:07 (EST)
	Giovanni Gulli	Sad but true revised Dear Dr Daftary, I missed your letter in the Annals, but, as of today, it it hanging outside my office door. Thank you for describing with lucidity our sad destiny. If I may, I would rephrase your sentence about our remaining role adding a third category, i.e., the chronically ill whose medical problems are beyond established guidelines. Author's disclosure (Feb 6, 2013) I have no relevant disclosures to make in connection with this topic.
	# 26 of 28	March 1, 2013 07:09 (EST)
	Allison Brink	Communication is Key I believe hospitalists can be beneficial in the care of the patient at the hospital. I worked as an ICU nurse for many years and witnessed many family doctors trying to manage patients that were beyond their abilities to manage. That being said, I believe communication is very important. The PCP should be included in making the plan for the patient and the plans for discharge. The patient needs a team while in the hospital and the PCP is an important part of that team. Author's disclosure (Mar 1, 2013) I have no relevant disclosures to make in connection with this topic.
	# 27 of 28	March 5, 2013 08:11 (EST)
	william reichert	PCP involvement If a PCP wants to come to the hospital and keep up with what is going on that is fine. Occasionally that happens. And when it does it is really good/ However, that has to be done without pay or we would have 2 docs doing the job of one. Reviewing the care at discharge with the PCP on the phone is just not feasible. They cannot be reached for a conversation on the phone. They cannot be reached after hours at the hospital and on the week end. It just does not work. If the PCP wants to take care of her patients then they should.And we welcome that. We send a letter at discharge with a summary of what was done and what needs to be done for PCPs who do not want to take care of their patients in the hospital/ The decision to have hospitalists care for these patients is made by the PCP not by the hospitalist Author's disclosure (Feb 8, 2013) I have no relevant disclosures to make in connection with this topic.
	# 28 of 28	March 5, 2013 10:22 (EST)
	Melissa Walton-Shirley	The decision to have a hospitalist program ...... is often the decision of the CEO/system because they can place their PCP's in the office to crank out visits. Unfortunately many hospitals seem to hire shift workers with no investment in the community. After many conversations on the topic, the systems that have worked well is when community docs provide the "hospitalist" work. Right now, many places in the US are struggling, trying to make the best of a difficult situation. Author's disclosure (Feb 4, 2013) I have no relevant disclosures to make in connection with this topic.

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