It is unfortunate that the nursing home nurse did not call the patient’s primary care physician upon transfer, but it was even more unfortunate that her PCP was not contacted at any time during her emergency room stay or subsequent hospitalization by any of the doctors who saw her. Had they called Mrs. P’s PCP, they would have learned that she had a long history of progressive dementia and similar unresponsive episodes in the past that had been fully evaluated. Further, they would have learned that she always carried bacteria in her urine without tissue invasion and that she could have received any of her treatments in the nursing home where she would have been safer and more comfortable, at a far lower cost. A recent study showed that 20% of hospitalized patients who receive antibiotics develop an adverse event, so avoiding unnecessary antibiotics must be a top priority.
The growth of the hospitalist movement over the past twenty years has been truly phenomenal—at 50,000 physicians, it is the largest medical sub specialty, surpassed as a specialty only by general internal medicine at 109,000 and family medicine at 107,000. Studies suggest that quality was improved and costs reduced with hospitalist care. This was especially true for complicated patients who required multiple physician visits and interactions each day, something increasingly difficult for the community-based PCP to achieve.
The hospitalist is experienced in managing the types of medical issues that lead to hospitalization and works full time in the hospital. As a result, they come to know how to “get things done” and potentially can give more efficient care. But they are far too often burdened with large numbers of patients, and often know very little about the patients they are treating. With too many patients to care for and too little information, they tend to request consultations for problems that, given adequate time, they could have managed. This is especially problematic if the patient has multiple medical issues and is elderly. Other reasonable concerns are the diminishment of the patient-physician relationship and miscommunication and discoordination at both admission and discharge. Communication with the patient’s PCP could alleviate many of these issues.
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PCPs have been generally content to allow the hospitalist to manage their patients; indeed it has been a major advantage for many. PCPs have seen their overhead costs rise dramatically, necessitating seeing more and more patients per day for less and less time each in order to cover those overhead costs. The multitude of rules, regulations and requirements foisted upon them by the insurers has further consumed extensive time—time that previously could be used to care for their hospitalized patients. Today, many PCPs do not have time to see patients in the hospital, while others are barred from doing so by hospital rules.