The concept of a physician who works only in the hospital developed from the common-sense realization that we can’t be in two places at once. Starting in the 1990’s when the word “hospitalist” was first coined, primary care doctors and specialists alike have seen us as a way to ensure that when their patients need hospitalization, they will get care from a doctor skilled at inpatient care.
Spending all our time in hospitals, we know who does what and how to get things done. We have spent time learning the computer system that accesses information from patients’ vital signs to their lab and X-ray results, we know the nurses and technicians and which consultants give the best service. And unlike a primary care doctor or specialist with an office practice, we’re available 24-7.
The standard of care for hospitalists is simply that of quality medicine. We do, however, have some challenges that a full-service internist or pediatrician lacks, most of them involving continuity of care.
Patient handoffs may be from one hospitalist to another, from outpatient doctor to hospital and vice versa, or between hospitals when the patient is transferred. Many hospitalists work a “7 days on, 7 days off” schedule or cover for each other on weekends, and it’s critical that all necessary facts and problems be communicated either verbally or in writing (often with HIPAA-compliant e-mail). If an office doctor refers a patient for admission there should be documentation of the previous medical history, often as copies of clinic records. Inter-hospital transfers should result in a complete history and physical exam that lists the important events and test results at the first hospital along with diagnoses and plans for evaluation and treatment.
When a hospitalist discharges a patient there should be some notation of what followup care is needed and where it will be done. While the patient has some responsibility for getting to the follow-up doctor, any complicated events, ongoing problems or still-unreported test results should prompt direct communication between the hospitalist and the next doctor who will see the patient.
Another big problem for hospitalists is, quite simply, other doctors. If we’re the primary doctor on the case we often need help from other specialists. I ask that you use common sense in deciding just how responsible we should be for other doctors’ work: we can’t supervise everything they do, but we should be aware of what is happening and take action if things are going wrong. If the neurosurgeon is ignoring our calls about spinal cord problems we need to fire him or transfer the patient elsewhere; if the kidney specialist orders an antibiotic that could worsen a neurologic problem we need to speak up. Sometimes the line between our responsibility and that of our colleagues isn’t quite so clear…but that’s why you call on experts, isn’t it?
Some suits involving hospitalists are prompted less by substandard care than by patient and family impressions. The hard fact is that most of our patients have never met us before they came to the hospital, and they were sick at the time. If the hospitalist group is short-handed or the doctor has a foreign accent the impression will be even worse regardless of the quality of care, and any adverse event will bring them to your office. I only ask that you remember that “She was just fine until she went to that place” does not mean that malpractice was involved.
With more and more studies showing that hospitalists can improve both the quality and cost-effectiveness of inpatient care, you’re going to be seeing and hearing about us a lot. And our expertise can help your clients as well as our patients.
Expert Witness No. 2711, MD, FACP is board-certified in internal medicine and has been a hospitalist since 2002. She writes professionally both for the public and for other doctors.
Written by Medical Internist Expert Witness
Expert Witness No. 2711
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